Gebrüder Martin GmbH & Co. KG
KLS Martin Platz 1
D-78532 Tuttlingen/Germany
Test result
☐
No defects found. The system can be kept in service.
☐
The system can be kept in service despite deficiencies.
The defects/deficiencies found will be corrected by:
Date:
☐
The defects found require immediate maintenance or repair of the
system before its next use, as otherwise patients, users or third
parties would be at risk.
The defects/deficiencies found will be corrected by:
Date:
☐
All defects have been removed in a technically correct manner.
The system can be kept in service.
Date:
The customer has been informed that an inspection according to the inspection plan must be performed
every 24 months by an authorized person.
If
N/A
has been ticked in at least one position even though the object to be tested is present, it is
mandatory to indicate in the field
Comment
the reason why it was not possible to carry out the
corresponding test (e.g. object not accessible, defective).
Test
equipment used (ID №):
Comment:
Place, date:
Signature
Operator/customer
Inspector/service technician
