Certificate of Compliance with Healthcare Engineering Requirements

(***please select***) (Cap. 633)

Medical gas pipeline system

Section A

Information of the ***please select*** and service covered by the application:

***please select***	:	Example: ABC Endoscopy Centre
Service	:	Example: Endoscopic procedure, anaesthetic procedure
Service Location	:	Example: Unit 1003, 10/F, DEF Commercial Centre, XXX Nathan Road, Mongkok, Kowloon, Hong Kong

Section B

I, as the (***please select***) of the ***please select***, declare that I have arranged a Registered Professional Engineer (R.P.E.) to certify in Section C that the medical gas pipeline system(s) for the service described in Section A to be in compliance with the requirements in the ***please select***, and I hereby warrant that the medical gas pipeline system(s) comply with the requirements of the ***please select***.

Name	:	Example: CHAN Tai Man
Post Title	:	Example: Chief Medical Executive
Signature	:
Date	:
Company Chop	:

Section C

I, as a Registered Professional Engineer (R.P.E.), certify that the medical gas pipeline system(s) for the service described in Section A have been designed, installed and completed in compliance with the ***please select***, and in accordance with the specified standard(s) (namely ***please specify*** ) and requirements described herewith.

Location	Piped Medical Gas	Nominal Pressure (kPa)	Designed Flow for each Terminal Unit (L/min)	Diversified Flow (L/min)
Example: Operating Room	Oxygen (O2) Medical air (MA4) Medical Vacuum	400 400 40	100 40 40	100 40 40
Example: Recovery Area	Oxygen (O2) Medical air (MA4) Medical Vacuum	400 400 40	10 40 40	10 40 40
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-	-	-	-	-
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-	-	-	-	-
-	-	-	-	-
-	-	-	-	-
-	-	-	-	-

Section C (cont.)

The particulars of the medical gas pipeline system(s) are shown in the following schematic diagrams(s) and layout plan(s):

Drawing No.	Revision	Drawing Title
Example: MG/S/01	1	Medical Oxygen Supply Schematic Diagram
Example: MG/S/02	0	Medical Air Schematic Diagram
Example: MG/S/03	0	Medical Vacuum Schematic Diagram
Example: MG/L/01	0	MGPS Layout Plan at 10/F
Example: MG/L/02	1	MGPS Layout Plan at OR and Recovery Area
-	-	-
-	-	-

I also confirm that I have personally inspected the medical gas pipeline system(s) covered by this certificate and the results of the inspection are satisfactory.

Name	:	Example: LEE Chi Nan
R.P.E. Number	:	Example: RPE123456
Discipline	:	Please select
Signature	:
Date	:

A Registered Professional Engineer certifying a medical gas pipeline system shall be registered in the mechanical discipline or building services discipline with the Engineers Registration Board under the Engineers Registration Ordinance (Cap. 409).