Republic of the Marshall Islands
Ministry of Health and Human Services
Lerooj Atama Zedkaia Memorial Hospital
Maintenance Request Form
Submitted By
Email
Phone Number
Department
-- Select Department --
Emergency Room
Outpatient
Pediatrics
Inpatient Ward
Surgery / Operating Room
Pharmacy
Radiology / X-ray
Rehabilitation
Laboratory
Public Health / Immunization
Environmental Health
Facilities / Maintenance
Administration / HR
Finance / Accounting
Medical Records
Dental Services
Support Services
Other
Issue Category
-- Select Issue Category --
Electrical (e.g., lighting, wiring, outlets)
Plumbing (e.g., leaks, drainage, toilets)
HVAC / Air Conditioning (e.g., not cooling, noisy unit)
Carpentry / Fixtures (e.g., doors, windows, shelves)
Painting / Surface Repairs
Roofing / Ceiling Leaks
Flooring / Tiles
Sanitation / Cleaning Requests
Pest Control (e.g., insects, rodents)
Other
Priority Level
Low
Medium
High
Emergency
Facility/Location
Floor Level
-- Select Floor --
Ground
1st
2nd
3rd
Issue Description
Upload Photo (Optional)
Click to select a photo
Submit Request
Do you want to submit this maintenance request?
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