Republic of the Marshall Islands

Ministry of Health & Human Services

Maintenance Request

Anything broken, leaking, noisy or not working

If the fault is with a machine that has a QR sticker, scanning it instead fills this in for you and links the report to that machine's history.

What is wrong? *

What you can see or hear is more useful than a guess at the cause. "Broken" earns a second visit; "leaking from the base" does not.

How urgent is it?

CriticalA patient is at risk, or care has stopped HighWe can work, but it is affecting patients NormalIt can wait for the next visit

Photo (optional)

A picture of the fault, the error on the screen, or the label on the machine. Up to three. This is often what saves the technician a second trip.

So the technician can find it

Ward or department

Room or area

What kind of problem

Leave it as "not sure" if you do not know — that is fine.

In case the technician needs to ask

Your name *

Phone or extension

We will send you a copy, and tell you when it is done.

If a patient is at risk right now, call the maintenance office instead of filling this in. This form is read during working hours.

Public Health Infrastructure Grant — Data Modernization Initiative
© 2026 Ministry of Health & Human Services, Republic of the Marshall Islands