Run Modality Equipment Inspection and Calibration Log — Free

Inspection Details

Inspection date and time recorded critical (required)

Inspector name and role documented critical (required)

Equipment asset ID / serial number documented critical (required)

Equipment type identified critical (required)

Inspection interval is current per facility schedule critical (required)

Confirm the inspection is being completed at the required scheduled interval, such as annual or facility-defined preventive maintenance frequency.

Yes No N/A

Visual Condition and Labeling

Power cord, plug, and strain relief free of cuts, fraying, or exposed conductors critical (required)

Yes No N/A

Photo evidence (optional)

Housing, controls, display, and connectors intact with no cracks or missing parts critical (required)

Yes No N/A

Photo evidence (optional)

Safety labels, warnings, and operating instructions legible and present

Yes No N/A

Accessory cables, applicators, transducers, and pads are clean and undamaged critical (required)

Yes No N/A

Photo evidence (optional)

Device is clean, dry, and free of visible contamination

Yes No N/A

No visible signs of overheating, liquid intrusion, or burn damage critical (required)

Yes No N/A

Photo evidence (optional)

Calibration and Functional Performance

Calibration status current and within required interval critical (required)

Confirm calibration has been completed according to manufacturer guidance and facility policy. Annual calibration is commonly required for modality equipment.

Yes No N/A

Ultrasound output verified within acceptable range critical (required)

Record measured output or calibration result for ultrasound units using the facility-approved test method.

E-stim output verified within acceptable range critical (required)

Record measured output or calibration result for electrical stimulation units using the facility-approved test method.

Traction force verified within acceptable range critical (required)

Record measured traction force or calibration result using the facility-approved test method. If the unit uses a different scale, enter the measured value in the unit specified by the manufacturer.

Timer, intensity, mode, and output controls respond correctly critical (required)

Yes No N/A

Emergency stop, pause, or output shutoff functions operate correctly critical (required)

Yes No N/A

Patient Safety Controls and Environment

Grounding, isolation, and electrical safety checks completed per policy critical (required)

Yes No N/A

Cables and leads routed to prevent trip hazards and accidental disconnection

Yes No N/A

Treatment area clear of obstructions and safe for patient use

Yes No N/A

Emergency call device or staff access available during treatment setup critical (required)

Yes No N/A

PPE and infection control supplies available as required by facility policy

Yes No N/A

Equipment removed from service if any unsafe condition is identified critical (required)

If a deficiency is found, the device must be tagged out and not used until repaired and rechecked.

Yes No N/A

Deficiencies, Corrective Actions, and Closeout

Deficiencies or non-conformances documented

List each deficiency, affected component, and observed condition.

Corrective action assigned with responsible person and due date

Equipment tagged out or returned to service status documented critical (required)

Inspector signature completed critical (required)

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Run: Modality Equipment Inspection and Calibration Log

Inspection Details

Visual Condition and Labeling

Calibration and Functional Performance

Patient Safety Controls and Environment

Deficiencies, Corrective Actions, and Closeout

Get your results