Summary
Delivery • Access • Rigging • Site Coordination • Startup Readiness
Purpose:
This form confirms that delivery access, rigging needs, staffing, staging, and startup coordination are fully resolved before equipment ships. This prevents delivery refusal, freight damage, emergency crane charges, infection control violations, and commissioning delays.
Project & Facility Information
- Facility Name: __________________________________________
- Install Address: _______________________________________
- City / State / Zip: _____________________________________
- Department / Room: ____________________________________
- Project / PO Number: __________________________________
- Target Delivery Date: _________________________________
- Target Install / Startup Date: __________________________
Primary Site Contact:
- Name: ________________________________________________
- Title: ________________________________________________
- Phone: _______________________________________________
- Email: _______________________________________________
Equipment Being Delivered
- Manufacturer: ________________________________________
- Model Number: _______________________________________
- Ice Type: ☐ Full Cube ☐ Half Cube ☐ Nugget ☐ Flake ☐ Dispenser
- Estimated Weight (crated): ___________________________
- Crated Dimensions (L × W × H): ________________________
- Bin Included: ☐ Yes ☐ No
- Multiple Units Shipping Together: ☐ Yes ☐ No
Delivery Type & Receiving Conditions
☐ Standard dock delivery
☐ Liftgate delivery required
☐ Inside delivery required
☐ After-hours delivery required
☐ Weekend delivery required
Receiving Area:
☐ Loading dock
☐ Ground-level entrance
☐ Service corridor
☐ Public entrance (special approval required)
Receiving Limitations:
- Dock height restriction? ☐ Yes ☐ No
- Vehicle size restriction? ☐ Yes ☐ No
- Security clearance required? ☐ Yes ☐ No
- Appointment required? ☐ Yes ☐ No
Receiving Hours: _________________________________
Path of Travel Verification (CRITICAL)
☐ Clear path from receiving point to final install location
☐ All door widths measured and adequate
☐ Elevator required ☐ Yes ☐ No
- Elevator weight rating: ___________________________
- Elevator cab dimensions: __________________________
☐ No stairs in path
☐ If stairs present → Rigging plan attached
☐ Floor protection required ☐ Yes ☐ No
If path is NOT fully clear, describe obstruction:
Rigging, Forklift & Crane Requirements
☐ Pallet jack only
☐ Forklift required
☐ Crane required
☐ Specialty rigging required
If crane or rigging is required:
- Crane vendor assigned: __________________________
- Crane date reserved: ____________________________
- Street closure permit required ☐ Yes ☐ No
- Structural lift clearance verified ☐ Yes ☐ No
Staging & Storage
☐ Equipment will be installed immediately upon delivery
☐ Temporary indoor staging required
☐ Outdoor staging required (not recommended)
If staging is required:
- Location: _________________________________________
- Climate-controlled ☐ Yes ☐ No
- Secured area ☐ Yes ☐ No
- Maximum days in staging: __________________________
Infection Control & Occupied Facility Planning
(Healthcare, VA, Long-Term Care)
☐ Infection Control Risk Assessment completed
☐ Above-ceiling work coordination approved
☐ Dust containment required
☐ Off-hours installation required
☐ Negative air required
☐ Patient traffic routed away from work area
Approval Authority: _________________________________
Installer & Trade Coordination
☐ Installer assigned
☐ Plumber scheduled
☐ Electrician scheduled
☐ Filtration installer scheduled
☐ Drain pump installer scheduled (if required)
All trades scheduled for same day: ☐ Yes ☐ No
Trade Company Names:
- Installer: ______________________________________
- Plumbing: _______________________________________
- Electrical: ______________________________________
Startup & Commissioning Readiness
☐ Power live and tested
☐ Drain tested with continuous flow
☐ Filtration installed and active
☐ Water pressure verified
☐ Ventilation operational
☐ Clearance verified
☐ Ice testing planned at startup
☐ Staff training scheduled
Logistics Risk Review
Check any identified risks:
☐ Tight doorway clearance
☐ Elevator capacity concern
☐ Long internal travel distance
☐ Infection control restriction
☐ Off-hours delivery required
☐ Structural load concern
☐ Weather-related delivery risk
Mitigation Plan:
FINAL LOGISTICS DETERMINATION
☐ LOGISTICS APPROVED — OK TO SHIP
☐ NOT APPROVED — CORRECTIONS REQUIRED BEFORE SHIPMENT
Outstanding Issues:
Authorization & Sign-Off
Project Manager / Coordinator:
Name: _____________________________________________
Signature: __________________________________________
Date: ______________________________________________
Facility Representative:
Name: _____________________________________________
Signature: __________________________________________
Date: ______________________________________________
SHIPPING HOLD NOTICE
Equipment must not be released for freight if this form is incomplete or “Not Approved.”
Doing so exposes all parties to:
- Delivery refusal
- Emergency rigging costs
- Freight damage
- Infection control violations
- Missed startup
- Restart and re-mobilization charges
