SECTION
F
36
Field Inspection Report
Assure
®
P
ris
m
m
ul
ti Blood Glucose Monitoring System
Facility:
_________________________________
Date:
___________________________
Contact:
______________________________
Address:
________________________________
Time:
___________________________
Phone:
________________________________
_________________________________
ARKRAY Representative Signature:
__________________________________________
Comments:
__________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_________________________________________
N
am
e of
f
ac
ili
ty
: ________________________________
Minneapol
is, MN 55439 USA
TEL 800.818.8877
FAX 952.646.3110
www
.arkra
yusa.com
Station
Meter Serial #
Contr
ol 1 – Contr
ol Solution
Contr
ol 2 – Contr
ol Solution
Time and Date Corr
ect
Meter
Replaced
Replacement Meter Serial #
Range
Result
Range
Result
(Y
/N)
(Y
/N)
Summary of Contents for Assure PRISM MULTI
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