DIVA HEALTHCARE PVT.

LTD DIVA EYE INSTITUTE

17, Parimal Society, Core House Lane 17, Parimal Society, Core House Lane
Parimal Garden, Ahmedabad: 380006 Parimal Garden, Ahmedabad: 380006

H E A LT H C A R E P V T. LT D .

DIVA EYE INSTITUTE

Fumigation Form
Name:………………………………………………………………………………………………………………………………………..

Place:………………………………………………………………………………………………………………………………………….

Address:
……………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

Name of Fumigant used:…………………………………………………………………………………………………………………….

Place of Fumigant:……………………………………………………………………………………………………………………………..

Dosage rate:………………………………………………………………………………………………………………………………………

Date of fumigation:…………………………………….

Air Pressure:……………………………………………….

Duration of fumigation:……………………………..

Describe the process:……………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………..

Name of fumigant incharge:……………………………………………………………………………………………………………..

Date :……………………………………….

Place :………………………………………

Name and signature:………………………………………………………………

Note** To be filled by- nursing supdt
When to be filled- In case where fumigation is carried out.
Where to be recorded- fumigation maintenance register/file.
DIVA HEALTHCARE PVT. LTD DIVA EYE INSTITUTE
17, Parimal Society, Core House Lane 17, Parimal Society, Core House Lane
Parimal Garden, Ahmedabad: 380006 Parimal Garden, Ahmedabad: 380006

H E A LT H C A R E P V T. LT D .

DIVA EYE INSTITUTE

Note** To be filled by- nursing supdt

When to be filled- In case where fumigation is carried out.
Where to be recorded- fumigation maintenance register/file.