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001 - 17 Form Checklist Uji Fungsi CT

This document is a function check form for a medical imaging system. It lists 15 safety and functional tests to check components like the power supply, emergency stop circuit, radiation indicators, patient table movement, gantry movement and installation. Each test includes a checkbox to mark if it passed or failed. The form provides details to test technicians on tests to perform and document the condition of the system.

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Adietz satya
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62 views1 page

001 - 17 Form Checklist Uji Fungsi CT

This document is a function check form for a medical imaging system. It lists 15 safety and functional tests to check components like the power supply, emergency stop circuit, radiation indicators, patient table movement, gantry movement and installation. Each test includes a checkbox to mark if it passed or failed. The form provides details to test technicians on tests to perform and document the condition of the system.

Uploaded by

Adietz satya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SYSTEM Form No.

: 001/HC/CT/EMO
Rev. No. : 00.2017
FUNCTION CHECK FORM
Date : 21.11.2017
(LEMBAR UJI FUNGSI) Page : 1 of 1

Hospital : Equipment Name :


Address : Article Number :
Town : Serial Number :
Department : Check List No. :
Date :

Function Check System


□ New system installation □ Existing system □ System relocation
Safety Related Test OK not OK
1. Check on-site power supply □ □
L1-L2 : …………. VAC L1-N : …………. VAC
L1-L3 : …………. VAC L2-N : …………. VAC
L2-L3 : …………. VAC L3-N : …………. VAC
Gnd-N : …………. VAC
2. Emergency STOP circuit checked □ □
3. Radiation cut off checked □ □
4. Radiation indicator checked □ □
5. Door contact switch checked □ □
6. Patient positioning aids checked □ □
Patient Table
7. Inspect for damages and loose parts □ □
8. Check table movement □ □
9. Check the anchoring of the patient table to the floor □ □
Gantry
10. Inspect for damages, loose parts, cracks/ tears and screw connections □ □
11. Check the anchoring of the gantry to the floor □ □
12. Check Gantry tilting and rotation □ □
13. Check ICS and IRS booting sequence □ □
14. Check UPS Load (optional) □ □
15. Perform Tune Up and Quality check □ □
Checked by : Siemens Healthineers Witnessed by :
Name : Name :
Signature : Signature :

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