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Medrad Mark V Provis
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1
Medrad Mark V Provis
*
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2
BMET Name
*
This field is required.
First Name
Last Name
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3
Email
*
This field is required.
your.name@trimedx.com
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4
Date
*
This field is required.
-
Date
Month
Day
Year
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5
Work Order Number
*
This field is required.
WOT
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6
SID/CEID
*
This field is required.
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7
Hospital Name
*
This field is required.
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8
Department
*
This field is required.
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9
Room
*
This field is required.
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10
Display Serial Number
*
This field is required.
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11
Head Mounting Type:
*
This field is required.
Please Select
Table Mounted
Pedestal
Ceiling
Please Select
Please Select
Table Mounted
Pedestal
Ceiling
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12
CRU Version
*
This field is required.
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13
1. Clean/Inspect Display and Main Unit
*
This field is required.
Pass
Fail
Not Applicable
Display Screen
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Hand Switch
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Main Unit Cables and Power Cord
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Injector Head Faceplate
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Plunger Rotation Lever
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Turret
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Head Mounting Device
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Display Screen
Hand Switch
Main Unit Cables and Power Cord
Injector Head Faceplate
Plunger Rotation Lever
Turret
Head Mounting Device
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Not Applicable
Row 0, Column 2
Pass
Row 1, Column 0
Fail
Row 1, Column 1
Not Applicable
Row 1, Column 2
Pass
Row 2, Column 0
Fail
Row 2, Column 1
Not Applicable
Row 2, Column 2
Pass
Row 3, Column 0
Fail
Row 3, Column 1
Not Applicable
Row 3, Column 2
Pass
Row 4, Column 0
Fail
Row 4, Column 1
Not Applicable
Row 4, Column 2
Pass
Row 5, Column 0
Fail
Row 5, Column 1
Not Applicable
Row 5, Column 2
Pass
Row 6, Column 0
Fail
Row 6, Column 1
Not Applicable
Row 6, Column 2
1
of 7
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14
2. Clean/Inspect Injector Head
*
This field is required.
Pass
Fail
N/A
Injector Head Components
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Pivot Knuckle and Gasket
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Head Cable
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Mechanical Stop Motor
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Mechanical Stop Plate
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Injector Head Components
Pivot Knuckle and Gasket
Head Cable
Mechanical Stop Motor
Mechanical Stop Plate
Pass
Row 0, Column 0
Fail
Row 0, Column 1
N/A
Row 0, Column 2
Pass
Row 1, Column 0
Fail
Row 1, Column 1
N/A
Row 1, Column 2
Pass
Row 2, Column 0
Fail
Row 2, Column 1
N/A
Row 2, Column 2
Pass
Row 3, Column 0
Fail
Row 3, Column 1
N/A
Row 3, Column 2
Pass
Row 4, Column 0
Fail
Row 4, Column 1
N/A
Row 4, Column 2
1
of 5
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15
2. Clean/Inspect Injector Head Continued
*
This field is required.
Pass
Fail
N/A
MS Worm Gears
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Ball Screw Gear and Piston
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Piston
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Pressure Jacket
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
MS Worm Gears
Ball Screw Gear and Piston
Piston
Pressure Jacket
Pass
Row 0, Column 0
Fail
Row 0, Column 1
N/A
Row 0, Column 2
Pass
Row 1, Column 0
Fail
Row 1, Column 1
N/A
Row 1, Column 2
Pass
Row 2, Column 0
Fail
Row 2, Column 1
N/A
Row 2, Column 2
Pass
Row 3, Column 0
Fail
Row 3, Column 1
N/A
Row 3, Column 2
1
of 4
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16
2. Clean/Inspect Injector Head Continued
*
This field is required.
Pass
Fail
N/A
Head Mounting Device
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Head Cable
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Pistons
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Head Mounting Device
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Head Mounting Device
Head Cable
Pistons
Head Mounting Device
Pass
Row 0, Column 0
Fail
Row 0, Column 1
N/A
Row 0, Column 2
Pass
Row 1, Column 0
Fail
Row 1, Column 1
N/A
Row 1, Column 2
Pass
Row 2, Column 0
Fail
Row 2, Column 1
N/A
Row 2, Column 2
Pass
Row 3, Column 0
Fail
Row 3, Column 1
N/A
Row 3, Column 2
1
of 4
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17
3. Operational Checks
*
This field is required.
General Operation Check Inputs Injection Volume: 50 ml Injection Flow Rate: 10.0 ml/s Injection Pressure: 600 Rise Time: 0.0
Pass
Fail
N/A
Display Lights
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Injector Head Lights
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Mechanical Stop Set
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Syringe Heater (If Applicable)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Electronic Brake
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Display Lights
Injector Head Lights
Mechanical Stop Set
Syringe Heater (If Applicable)
Electronic Brake
Pass
Row 0, Column 0
Fail
Row 0, Column 1
N/A
Row 0, Column 2
Pass
Row 1, Column 0
Fail
Row 1, Column 1
N/A
Row 1, Column 2
Pass
Row 2, Column 0
Fail
Row 2, Column 1
N/A
Row 2, Column 2
Pass
Row 3, Column 0
Fail
Row 3, Column 1
N/A
Row 3, Column 2
Pass
Row 4, Column 0
Fail
Row 4, Column 1
N/A
Row 4, Column 2
1
of 5
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18
Voltages / PSP Card
*
This field is required.
General Operation Check Inputs Injection Volume: 50 ml Injection Flow Rate: 10.0 ml/s Injection Pressure: 600 Rise Time: 0.0
Pass
Fail
+15 VDC (± 0.6)
Row 0, Column 0
Row 0, Column 1
-26 VDC (± 2.6)
Row 1, Column 0
Row 1, Column 1
-15 VDC +/- 0.6 VDC
Row 2, Column 0
Row 2, Column 1
+ 5.0 VDC + 0.2 VDC -0.1VDC
Row 3, Column 0
Row 3, Column 1
+26 VDC +/- 3.0 VDC
Row 4, Column 0
Row 4, Column 1
+15 VDC (± 0.6)
-26 VDC (± 2.6)
-15 VDC +/- 0.6 VDC
+ 5.0 VDC + 0.2 VDC -0.1VDC
+26 VDC +/- 3.0 VDC
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
Pass
Row 4, Column 0
Fail
Row 4, Column 1
1
of 5
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19
SCC card DAC Voltages
*
This field is required.
General Operation Check Inputs Injection Volume: 50 ml Injection Flow Rate: 10.0 ml/s Injection Pressure: 600 Rise Time: 0.0
Pass
Fail
DAC Voltage 8.80 V(+/- 0.6 V)
Row 0, Column 0
Row 0, Column 1
DAC Voltage 7.20 V(+/- 0.5 V)
Row 1, Column 0
Row 1, Column 1
DAC Voltage 5.40 V(+/- 0.4 V)
Row 2, Column 0
Row 2, Column 1
DAC Voltage 3.80 V(+/- 0.3 V)
Row 3, Column 0
Row 3, Column 1
DAC Voltage 2.00 V(+/- 0.2 V)
Row 4, Column 0
Row 4, Column 1
DAC Voltage .32 V (+/- 0.08 V)
Row 5, Column 0
Row 5, Column 1
DAC Voltage 8.80 V(+/- 0.6 V)
DAC Voltage 7.20 V(+/- 0.5 V)
DAC Voltage 5.40 V(+/- 0.4 V)
DAC Voltage 3.80 V(+/- 0.3 V)
DAC Voltage 2.00 V(+/- 0.2 V)
DAC Voltage .32 V (+/- 0.08 V)
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
Pass
Row 4, Column 0
Fail
Row 4, Column 1
Pass
Row 5, Column 0
Fail
Row 5, Column 1
1
of 6
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20
SCC card DAC Voltages Continued
*
This field is required.
General Operation Check Inputs Injection Volume: 50 ml Injection Flow Rate: 10.0 ml/s Injection Pressure: 600 Rise Time: 0.0
Pass
Fail
RF Voltage 10.0 V (+/- 0.01 V)
Row 0, Column 0
Row 0, Column 1
PL Voltage 0.25 V (+ 0.0 V/- 0.02 V)
Row 1, Column 0
Row 1, Column 1
MS Voltage 0.86 V (+ 0.02 V/- 0.00V)
Row 2, Column 0
Row 2, Column 1
RF Voltage 10.0 V (+/- 0.01 V)
PL Voltage 0.25 V (+ 0.0 V/- 0.02 V)
MS Voltage 0.86 V (+ 0.02 V/- 0.00V)
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
1
of 3
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21
SCC card DAC Voltages Continued
*
This field is required.
General Operation Check Inputs Injection Volume: 50 ml Injection Flow Rate: 10.0 ml/s Injection Pressure: 600 Rise Time: 0.0
Pass
Fail
MC Voltage 9.40 VDC
Row 0, Column 0
Row 0, Column 1
Injection Time 4.00 sec +/- .2
Row 1, Column 0
Row 1, Column 1
Injection Volume 40 ml +/- .5ml
Row 2, Column 0
Row 2, Column 1
Current Null 0 VDC +/- 0.2 VDC
Row 3, Column 0
Row 3, Column 1
Velocity -4.8 VDC +/- .2 VDC
Row 4, Column 0
Row 4, Column 1
MC Voltage 9.40 VDC
Injection Time 4.00 sec +/- .2
Injection Volume 40 ml +/- .5ml
Current Null 0 VDC +/- 0.2 VDC
Velocity -4.8 VDC +/- .2 VDC
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
Pass
Row 4, Column 0
Fail
Row 4, Column 1
1
of 5
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22
PSI Pressure Limit Verification
*
This field is required.
Pressure Limit: 680 PSI (+/- 145) Flow Rate: 12.0 ml/sec Volume Rate: 120 ml Rise Time: 0.2
PSI Readings
300psi +/- 30 psi
Row 0, Column 0
600psi +/- 30psi
Row 1, Column 0
Per Minute Verification less than150 psi
Row 2, Column 0
Forward psi less than 250 psi
Row 3, Column 0
300psi +/- 30 psi
600psi +/- 30psi
Per Minute Verification less than150 psi
Forward psi less than 250 psi
PSI Readings
Row 0, Column 0
PSI Readings
Row 1, Column 0
PSI Readings
Row 2, Column 0
PSI Readings
Row 3, Column 0
1
of 4
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23
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
1
of 2
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24
Signature
*
This field is required.
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Should be Empty:
Question Label
1
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