APPENDIX A
OPRHT50NA B0908
A-5
HT50 Ventilator Quick Check
Pass / Fail Check-Off Sheet
Preparation for Use Tests
Indicate result for each test
Pre-Test Inspection Check
Pass _____ Fail ______
1.
Power Switchover Alarm Check
Pass _____ Fail ______
2.
Alarm & Indicators Check
Pass _____ Fail ______
High
▲
Paw Alarm
Pass _____ Fail ______
Low
▼
Paw Alarm
Pass _____ Fail ______
Humidifier Alarm (HT50-H,HT50-HB only)
Pass _____ Fail ______
3.
Paw Monitor / Pressure Meter Check
Pass _____ Fail ______
4.
Volume/Frequency Monitor Check
Pass _____ Fail ______
5.
Internal Battery Check
Pass _____ Fail ______
The ventilator is ready for operation when all tests have been completed
successfully.
Note any comments on inspection of unit, corrective action taken, or recommendations for
further action.
Completed by:
Date:
Facility:
Serial #:
Unit hours: