Certificate of Compliance with Healthcare Engineering Requirements (***please select***) (Cap. 633)

Specialized ventilation system

Section A

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

***please select***	:	Example: ABC Medical Centre
Service	:	Example: Surgical procedure, endoscopic procedure, anaesthetic procedure
Service Location	:	Example: Unit 1103, 11/F, ABC 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 specialized ventilation 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 specialized ventilation 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 specialized ventilation 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	Differential Pressure to Adjacent Areas (Pa)	Minimum Air Change per Hour (Outdoor air / Total air) (ACH)	Minimum Filter Efficiency (Outdoor air / Recirculating air)	Design Room Temperature (oC)	Design Relative Humidity (%)
Example: Operating Room	at least +2.5	4 / 20	MERV-16 / HEPA	20 - 24	20 - 60
-	-	-	-	-	-
-	-	-	-	-	-
-	-	-	-	-	-
-	-	-	-	-	-
-	-	-	-	-	-
-	-	-	-	-	-
-	-	-	-	-	-
-	-	-	-	-	-

Section C (cont.)

The particulars of the specialized ventilation system(s) are shown in the following schematic diagrams(s) and layout plan(s):

Drawing No.	Revision	Drawing Title
Example: AC/S/01	1	Air-conditioning and Mechanical System - Air-side Schematic Diagram
Example: AC/L/01	0	Air-conditioning and Mechanical System - Air-side Layout Plan at 11/F
-	-	-
-	-	-
-	-	-
-	-	-
-	-	-

I also confirm that I have personally inspected the specialized ventilation 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 (R.P.E.) certifying a specialized ventilation system shall be registered in the mechanical discipline or building services discipline with the Engineers Registration Board under the Engineers Registration Ordinance (Cap. 409).