
Page 73
MAINTENANCE
TEST AND EVALUATION REPORT
Defi ciency / Notes:
Overall Assessment:
No safety or functional defi ciencies were detected
No direct risk, defi ciencies detected may be corrected on short term
Equipment shall be taken out of service until defi ciencies are corrected
Next recurrent test necessary in:
3
months
6 months
12
months
Name:
__________________________
Signature:
__________________________
Date:
___________
Testing Organization:
_________________________
Name of Testing Person:
_______________________
Test before putting into service
(reference value)
Recurrent test
Test after repair
Responsible Organization:
_________________________________________________________
Equipment:
___________________________
ID – Number:
__________________________
Type:
________________________________
Serial Number:
________________________
Manufacturer:
Zimmer
Class of Protection:
Class I
Class II
Battery
Applied Part Type:
0
B
BF
CF
Mains Connection:
Permanently Installed
Non-detachable Power Cord
Detachable Power Cord
Accessories:
_______________________________________________________________________
Measuring Equipment:
_______________________________________________________________
Measurements: Specifi cation
Measured
Protective earth resistance:
<300m
Ω
_________
m
Ω
Earth (equipment) Leakage:
<500
μ
A _________
μ
A
Insulation Resistance:
>50M
Ω
_________M
Ω
Battery Health
>50%
_________%
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Functional Test:
Specifi cation
Function
DIAGNOSTIC OKAY (during startup)
Pass/Fail N/A
CALIBRATION OKAY (during startup) Pass/Fail N/A
PRESSURE set-point system test
Perform as described
Main
Second
TIME set-point system test
Perform as described
Main
Second
Low Pressure Alarm Check
Perform as described
Main
Second
Calibration (as required)
Perform as described
N/A
ATS Leak Test (loss/gain)
<-30mmHg/<+10mmHg Main___ Second___
Touch Test
Perform as described
N/A
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
N/A
Pass
Fail
Pass
Fail
Test
Results
Visual Inspection
Pass
Fail