Clone of Mark 7

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Medrad MrXperion* This field is required.
2
BMET Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Date* This field is required.
Date
Month
Day
Year
5
Work Order Number* This field is required.WOT
6
SID/CEID* This field is required.
7
Hospital Name* This field is required.
8
Department* This field is required.
9
Room* This field is required.
10
Display Serial Number* This field is required.
11
Head Serial Number* This field is required.
12
CRU Version* This field is required.
13
1. Clean/Inspect Display and Main Unit* This field is required.
Pass
Fail
Display Screen
Row 0, Column 0
Row 0, Column 1
Hand Switch
Row 1, Column 0
Row 1, Column 1
Display Screen
Hand Switch
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Pass
Row 1, Column 0
Fail
Row 1, Column 1
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2. Clean/Inspect Injector Head and Stand* This field is required.
Pass
Fail
Head Covers, Manual Knobs and Gaskets
Row 0, Column 0
Row 0, Column 1
Pedestal Covers and Casters
Row 1, Column 0
Row 1, Column 1
Drive Shaft Cables
Row 2, Column 0
Row 2, Column 1
Syringe Wells and Gasket
Row 3, Column 0
Row 3, Column 1
Head Covers, Manual Knobs and Gaskets
Pedestal Covers and Casters
Drive Shaft Cables
Syringe Wells and Gasket
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Pass
Row 1, Column 0
Fail
Row 1, Column 1
Pass
Row 2, Column 0
Fail
Row 2, Column 1
Pass
Row 3, Column 0
Fail
Row 3, Column 1
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3. Operational Checks* This field is required.General Injector Operation Phase 1 Contrast A: 5.0 mls, 50 ml Phase 2; Saline B: 10.0 mls, 100 ml 300 psi
Pass
Fail
Date and Time
Row 0, Column 0
Row 0, Column 1
Set Calibration Date
Row 1, Column 0
Row 1, Column 1
General Injector Operation
Row 2, Column 0
Row 2, Column 1
Forward/Reverse Load Buttons
Row 3, Column 0
Row 3, Column 1
Date and Time
Set Calibration Date
General Injector Operation
Forward/Reverse Load Buttons
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Pass
Row 1, Column 0
Fail
Row 1, Column 1
Pass
Row 2, Column 0
Fail
Row 2, Column 1
Pass
Row 3, Column 0
Fail
Row 3, Column 1
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5. Volume and Flow Rate Checks* This field is required.Injection Duration Syringe A/B: 5.0 ml/s secs, +/- 1 sec. Injection Volume Syringe A/B: 50 ml, +/- 1 ml. Injection Pressure: 300 psi
Seconds
ml
Syringe A 10 secs, +/- 1 sec/50 ml, +/- 1 m
Row 0, Column 0
Row 0, Column 1
Syringe B 10 secs, +/- 1 sec/50 ml, +/- 1 m
Row 1, Column 0
Row 1, Column 1
Syringe A 10 secs, +/- 1 sec/50 ml, +/- 1 m
Syringe B 10 secs, +/- 1 sec/50 ml, +/- 1 m
Seconds
Row 0, Column 0
ml
Row 0, Column 1
Seconds
Row 1, Column 0
ml
Row 1, Column 1
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PSI Pressure Limit Verification* This field is required.Contrast Side A Pressure Limit: 250 PSI (+/- 50) Flow Rate: 7.5 ml/sec Volume Rate: 60 ml Pressure Limit: 250 psi Saline Side B Pressure Limit: 250 PSI (+/- 50) Flow Rate: 8.0 ml/sec Volume Rate: 800 ml Pressure Limit:250 psi i
PSI Readings
Pressure Limit: 250 PSI (+/- 50)
Row 0, Column 0
Pressure Side B 250 psi(+/- 50)
Row 1, Column 0
Pressure Limit: 250 PSI (+/- 50)
Pressure Side B 250 psi(+/- 50)
PSI Readings
Row 0, Column 0
PSI Readings
Row 1, Column 0
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Electrical Safety Test* This field is required.Outputs should read mOhms <150 Output should read mA <500
Out Put Readings
mOhms
Row 0, Column 0
mA
Row 1, Column 0
mOhms
mA
Out Put Readings
Row 0, Column 0
Out Put Readings
Row 1, Column 0
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Signature* This field is required.
Should be Empty: