Emergency Power System - ICU Checklist

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System Activation & Transfer

1 of 7

Verification of automatic and manual transfer to emergency power.

Time of Emergency Power System Activation

12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM

Activation Method

Transfer Time (seconds)

Transfer Success?

Notes on Transfer Process (if any issues)

Synchronization Status

Voltage Level (Emergency Power)

Generator Performance

2 of 7

Assessment of generator operation during test run, including load acceptance and stability.

Generator Voltage (Volts)

Generator Frequency (Hz)

Load Acceptance Time (Seconds)

Generator Speed (RPM)

Engine Oil Pressure (PSI)

Coolant Temperature (Degrees F)

Observations & Anomalies

Time of Load Acceptance

12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM

Critical Equipment Verification

3 of 7

Confirmation that essential ICU equipment remains operational during and after transfer.

Ventilator Status

ECG Monitor Battery Level (%)

Infusion Pump Status

Patient Monitoring System (PMS) Status

Oxygen Concentrator Output (LPM)

Medical Air Pressure

Any observed abnormalities or issues with critical equipment

Lighting & HVAC

4 of 7

Verification of adequate emergency lighting and heating/cooling in the ICU.

Emergency Lighting Status

Emergency Lighting Lumens (average)

HVAC System Status

Room Temperature (°C) - measured

Room Temperature (°F) - measured

HVAC Airflow (observed)

Comments/Observations regarding Lighting and HVAC

Fuel Supply & Monitoring

5 of 7

Confirmation of sufficient fuel levels and proper monitoring systems.

Initial Fuel Level (Gallons/Liters)

Fuel Consumption During Test (Gallons/Liters)

Remaining Fuel Level (Gallons/Liters)

Fuel Type Verified?

Fuel Gauge Functionality

Last Fuel Delivery Date

Notes on Fuel Condition (e.g., cleanliness, odor)

System Shutdown & Return to Utility Power

6 of 7

Procedure for safely returning to normal utility power and system shutdown.

Time Utility Power Restored

12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM

Voltage Level (Utility Power)

Transfer Method to Utility Power

Observations During Return to Utility Power (e.g., voltage fluctuations, equipment behavior)

System Stability Upon Return

Date of Return to Utility Power

Any deviations from standard procedure during return to utility power? If so, describe.

Engineer Signature Verifying Return to Utility Power

Post-Test Documentation & Reporting

7 of 7

Recording of test results, anomalies, and corrective actions.

Date of Test

Start Time of Test

12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM

End Time of Test

12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM

Generator Load Acceptance (kW)

Transfer Time (Seconds)

Transfer Success?

Observations & Deviations

Equipment Functionality Verified (Select All That Apply)

Generator Data Log

Technician Signature

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