cek list biomedic

Biomedical. Eng

Preventive Maintenance Checklist

Equipment : Mac. Lab. Monitoring Date : __________________

Merk : MARQUET Period : __________________

Serial No. : _________________________ Room : __________________

Display housing ___________________________________

Computer module housing ___________________________________

Line / Power plug ___________________________________

Line / Power cord ___________________________________

Display fuse holder ___________________________________

System cables at rear of Display & ___________________________________Computer Module

Cable connectors ___________________________________

Rack & Parameter Module connectors___________________________________

Labeling and accessories ___________________________________

Patient safety checks ___________________________________

Indicators on / off and screen ___________________________________

LEDs on the parameter Module ___________________________________

Display performance ___________________________________

Visual and audible Alarm ___________________________________

Self-check procedures ___________________________________

Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meter

Remarks : ________________________________________________________

Performed by : _____________________ Verified by : _______________________

BM.0308.46/1

Biomedical. Eng


Equipment :PROCCESING FILM Date : __________________

Merk :KODAK Period : __________________

Serial No. : _________________________ Room : RADIOLOGI

Film Guide Assembly ____________________________________

Detector/Crossover Assemblies ____________________________________

Rollers ____________________________________Gears ____________________________________Guide Shoes ____________________________________Bearings ____________________________________Brackets ____________________________________Nuts ____________________________________

Squeegee Assembly ____________________________________

Rollers ____________________________________Gears ____________________________________Guide Shoes ____________________________________Bearings ____________________________________Brackets ____________________________________Nuts ____________________________________

Rack Assembly ____________________________________

Rollers ____________________________________Sprockets ____________________________________Chain ____________________________________Springs ____________________________________Rewet Rollers ____________________________________

Turnaround Assembly ____________________________________

Rollers ____________________________________Tubing ____________________________________

____________________________________

Main Drive Assembly ______________________________________________________________________

Plumbing ___________________________________

Connections ___________________________________Tubing ___________________________________

___________________________________

Recirculation System ___________________________________

Filter ______________________________________________________________________

Developer Temperature___________________________________

___________________________________

Water Flow to the Processor ______________________________________________________________________

Chemical Replenisher ______________________________________________________________________

Strainer Assembly ______________________________________________________________________

Dryer Section ___________________________________

Bearing ___________________________________Air Tube ___________________________________Roller ___________________________________O-Rings ___________________________________

Dryer Temperature ___________________________________

Test Equipment Used : ________________________________________________________

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Electrocardiograph Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________

Visual Inspection : Disconnect the cardiograph form AC power and inspect for theFollowing :

L Loss or missing hardware ____________________________

Frayed or damage wiring ____________________________

Mechanical damage ____________________________

Evidence of liquid spill ____________________________

Printer drive gear wear ____________________________

Printer roller wear ____________________________

Wear or damage to power cord andAssociated strain relief ____________________________

Corroded or damage electrodes ____________________________

Damage lead wires or patient module cable

____________________________

Dirt on thermal printer head ____________________________

Connect the cardiograph to AC power and turn on the AC switch.Verify the following :

The AC indicator is lit ____________________________

One or more green battery indicator are lit when On-Standby is

pressed

Turn on the cardiograph ____________________________

Extended Self-test : Run Extended self-test, select “ALL” menu choice and verify that

each test passes with no errors.

Patient module and cable ____________________________

CPU assembly ____________________________

Printer ____________________________

Preview display ____________________________

Keyboard display ________________________

Electrocardiograph Simulation : Record an ECG wave using an ECG simulator. Verify the following :

Trace activity for all 12 leads

No gross distortion of complexes or calibration pulses

Calibration pulses are of proper duration (200 ms) and amplitude (1

mV)

The trace will vary depending on simulation setting used and simulation type.calibration pulse measurements will vary depending on the cardiograph gain

and speed setting.

Comments : ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pulse Recorder :


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Treadmill Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________

Visual Inspection: Inspect the following for excess wear and/ or any visual signs of damage.

_____ Walking belt ____AC power cord _____ Internal cable and connectors

_____ Interface cable ____ Handrail hardware _____ Socketed components

_____ Drive beltCleaning___ use anti septic cleaner on the following areas: ___ Handrails ___ Shroud ____ Walking beltPower Supplies/Diagnostic test

-7.5 V dc ( 0,75) ____ Volts +16,5 V dc ( 1,65) ___Volts+5 V dc ( 0,5) ____ Volts +5 V -ISO ( 0,5) ___ Volts Speaker ___

Self calibration Speed calibration (2 mph)____mph (10 revolution in 38 seconds) Grade calibration (10 %) ____%

Electrical safety test AC line voltage test

___ Line to Neutral= 220 V Ground___ Line to Ground= 220 V ___ Neutral to Ground (< 3V) Neutral Line

Leakage testGround wire leakage to ground (100 uA max) Open ClosedChassis leakage to ground (exposed chassis) Normal Reversed Normal Reserved(100 uA max) NA NA ____uA ____uA

___uA ___uA NA NA Ground Continuity test

Ground pin to chassis ___ <0.1 ohmEnvironment

Room temperature_____(C) Humidity_____%Operational TestApply power to the Treadmill_____ Increase and decrease speed from minimum to maximum_____ Depress the emergency stop button (if attached ) while walking belt is spinning to confirm proper

operation _____ Raise and lower elevation from 0% to 25%._____ This completes the operational test.

Test Equipment Used : Tacho meter , Electric Safety Analyzer, ECG Stimulator

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng

LAPORAN PEMERIKSAAN ALAT BARU

Equipment : PATIENT MONITOR

Merk : ____________________ Date : __________________

Serial No. : _________________________ Room : __________________

Display housing ___________________________________

Computer module housing ___________________________________

Line / Power plug ___________________________________

Line / Power cord ___________________________________

Display fuse holder ___________________________________

System cables at rear of Display & ___________________________________Computer Module

Cable connectors ___________________________________

Rack & Parameter Module connectors ___________________________________

Labeling and accessories ___________________________________

Patient safety checks ___________________________________

Indicators on / off and screen ___________________________________

LEDs on the parameter Modules ___________________________________

Display performance ___________________________________

Visual and audible Alarm ___________________________________

Self-check procedures ___________________________________


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Electrocardiograph Date : __________________

Merk : Nihon kohden Period : __________________

Serial No. : _________________________ Room : __________________

Visual Inspection : Disconnect the cardiograph form AC power and inspect for theFollowing :

L Loss or missing hardware ____________________________

Frayed or damage wiring ____________________________

Mechanical damage ____________________________

Evidence of liquid spill ____________________________

Printer drive gear wear ____________________________

Printer roller wear ____________________________

Wear or damage to power cord andAssociated strain relief ____________________________

Corroded or damage electrodes ____________________________

Damage lead wires or patient module cable

____________________________

Dirt on thermal printer head ____________________________

Connect the cardiograph to AC power and turn on the AC switch.Verify the following :

The AC indicator is lit ____________________________

One or more green battery indicator are lit when On-Standby is

pressed

Turn on the cardiograph ____________________________

Extended Self-test : Run Extended self-test, select “ALL” menu choice and verify that

each test passes with no errors.

Patient module and cable ____________________________

CPU assembly ____________________________

Printer ____________________________

Preview display ____________________________

Keyboard display ________________________

Electrocardiograph Simulation : Record an ECG wave using an ECG simulator. Verify the following :

Trace activity for all 12 leads

No gross distortion of complexes or calibration pulses

Calibration pulses are of proper duration (200 ms) and amplitude (1

mV)

The trace will vary depending on simulation setting used and simulation type.calibration pulse measurements will vary depending on the cardiograph gain

and speed setting.

Comments : ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pulse Recorder :

Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meterRemarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Hypo/Hyperthermia Blanket Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________

1. External cabinet and control panel in good condition.

______________

2. All warning labels properly affixed. ______________

3. Quick disconnect coupling (tight, straight, not leaking)

______________

4. Power Cord (no cuts or exposed wire) and ______________

plug no (bent or missing pin)

5. Indicator lights (heat & cool , compressor, heaters, pump, power)

______________

6. Drain and clean reservoir ______________

7. Clean water filter ______________

8. Refill reservoir with distilled or sterile water

______________

9. Leakage current check ( all reading should be under 110 A for

______________

115/110 Volt AC and 500A for 230/240 Volt AC ) ______________

OFF normal polarity _____________________OFF reverse polarity _____________________ON normal polarity (heat) _____________________

ON reverse polarity (heat) _____________________ON normal polarity (cool) _____________________ON normal polarity (cool) _____________________

10 . Condition of blanket, hoses, coupling (check for leaks)

______________

11. Refrigerant test : a. Clean condenser and fan ______________

b. Check sight glass ______________

12. Check temperature ( high / low and limit) _______________________________

_______________________________

Test Equipment Used : DPM 3 Temp test, multi meter

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : ELECTROSURGICAL Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________

Calibration / Verification Checklist

S/N Physical/ Qualitative Test Pass Fail Electro surgical Quantitative Test

1 Chassis / Mounts/Fasteners A. Pure Cut Levels

2 Controls/Switches Selected Delivered ( Watts) Tolerance ( Watts)

3 Fittings/Connector 10 375 ±25

4 Cables/Accessories 7 245 ± 30

5 Indicators/Displays 5 160 ± 30

6 Foot Switch 2 35 ± 20

7 Isolation Switch B. Blends Levels

8 Low Frequency Output Selected Delivered ( Watts) Tolerance ( Watts)

9 REM Circuit 10 250 ±25

10 Cooling Fan Test 7 140 ±40

11 Power On Switch and Circuit Breaker 5 95 ± 20

2 25 ± 15

C. Coag Levels

Selected Delivered ( Watts) Tolerance ( Watts)

10 125 ± 15

7 75 ± 10

5 45 ± 10

2 10 ± 5

Test Equipment Used : RF 302 Electro surgical Analyzer

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : DEFIBRILATOR

Date :___________________________

Merk : ________________ Period :__________________________

Serial No. : ___________________ Room :__________________________

No Physical/Quantitative Test Pass Fail Calibration / Verification Checklist Koreksi

Defibrillator Quantitative Test

1 Chassis/Mounts /Fasteners Selected Delivered ( J ) Tolerance ( J )

2 Controls/Switches 10 8 - 12

3 Fittings/Connectors 20 16 - 24

4 Cables/Accessories 50 45 - 57

5 Battery/Charger 100 85 - 115

6 Indicator/Display 200 170 - 230

7 Alarms/Audible Signals 300 225 - 345

8 Recorder/Printer 360 306 - 414

9 Cardio version Test Paper Speed 25mm / 50 mm

10 Defib Paddles Int. Cal.Test Deliver

11 Safety Checks 100 Joule

12 Internal Cal. Test

Ket : J dalam satuan JOULE

Test Equipment Used : Defibrilator Analyzer QED 6

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. EngPreventive Maintenance Checklist

Equipment : Ventilator Date : _____________________

Merk : _________________________ Period : _____________________

Serial No. : _________________________ Room : _____________________

PPM CHECKLIST S/N Calibration/ Verification checklist Pass FailS/N Physical/Qualitative test Pass Fail 9 Tidal Volume

1 Chassis/Mounts/Fasteners 10 Total Rate 2 Controls/Switches 11 I : E Ratio 3 Fitting / Connectors 12 Manual Breath 4 Cable / Accessories 13 Alarm Silence 5 Battery / Charger 14 Expiration Time / Led 6 Indicator / Displays 15 Apnea Time 7 Alarms / Audible signals 16 Preset

17 Pressure (Peak, Mean,& Base) Calibration / Verification Checklist 18 Mode Selector

1 Flow 19 Trigger level a. Spontaneous Flow 20 Low Pressure Alarm B Main Flow 21 High Pressure Alarm

2 Respiratory Rate 22 External power Off/ 3 Inspiratory Time Power Disconnect Alarm 4 A/C Sigh 23 Battery power

5 Nebulizer 24 Low Battery Alarm 6 Peep 25 System Failure Alarm 7 Peak Inspiratory Pressure (PIP) 26 Fl O2 8 Leakage Test 27 Hour meter

Test Equipment Used : RT – 200 Calibration Analyzer

Remarks : ___________________________________________________________


BM.0308.46/


Equipment : Timbangan Bayi Date :

_____________________

Merk : SECA Period : _____________________

Serial No. : _________________________ Room : _____________________

Massa Nominal (g) Hasil Pembacaan(g) Toleransi (g)

5 _______________ 4,95-5,05

10 _______________ 9,9-10,1

50 _______________ 49,5-50,5

100 _______________ 99-101

500 _______________ 495-505

1000 _______________ 990-1010

5000 _______________ 4950-5050

10000 _______________ 9900-10100

Cek Fisik:

Battery :--------------------------------------------------------------------------------

Adaptor :--------------------------------------------------------------------------------

Pengukur tinggi :--------------------------------------------------------------------------------

Tare :-------------------------------------------------------------------------------

Display :-------------------------------------------------------------------------------

Test Equipment Used : ___________________________________________________________

Remarks : ___________________________________________________________

Performed by : _____________________ Verified by : ______________________

BM.0308.46


Equipment : Timbangan Date : _____________________

Merk : Period : _____________________

Serial No. : _________________________ Room : _____________________

Massa Nominal (kg) Hasil Pembacaan(kg) Toleransi (kg)

1 _______________ 0.99-1,01

5 _______________ 4,95-5,05

10 _______________ 9,9-10,1

20 _______________ 19,8-20,2

35 _______________ 34,65-35,35

50 ________________ 45,50-55,50

70 _______________ 69,3-70,7

100 ________________ 99-101

Cek Fisik:

Battery :--------------------------------------------------------------------------------

Adaptor :--------------------------------------------------------------------------------

Pengukur tinggi :--------------------------------------------------------------------------------

Tare :-------------------------------------------------------------------------------

Display :-------------------------------------------------------------------------------


Remarks : ___________________________________________________________


BM.0308.46

Biomedical. Eng


Equipment : Transport Incubator Date : __________________

Merk : _Datex Ohmeda_________ Period : __________________

Serial No. : _________________________ Room : __________________

NO Physical/Quantitative Test Pass Fail

1 Chassis/Mounts /Fasteners

2 Controls/Switches

3 Fiitings/Connectors

4 Cables/Accessories

5 Battery/Charger

6 Indicator/Display

7 Alarms/Audible Signals

8 Air oxygen system

9 Temperature

10 Infant Chamber

11 Air Flow System

12 Tank Inspection


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : DOPPLER Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________


1 Chassis / Mounts / Fasteners

2 Controls / Switches

3 Fiitings / Connectors

4 Cables / Accessories

5 Battery / Charger , Vdc

6 Indicator / Display

7 Alarm / Audible Signals

8 Tranduser

9 Cabel + Conector Tranduser

10 Beep

11 Calibrasi


Remarks : ________________________________________________________


BM 0308.46/1

Biomedical. Eng


Equipment : Bed Pasien Date :

__________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________




3 Fittings / Connectors


5 Indicator/Display

6 Hydraulic System

7 Brake System

8 Lubricating


Remarks : ________________________________________________________


BM 0308.46/1

Biomedical. Eng


Equipment : NBP MONITOR Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________









8 Manset

9 Self Test

10 Pump

11 Calibrasi


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : FETAL MONITOR / CTG Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________

NO Physical / Qualitative Test Pass Fail







7 Selft Test

8 Tranducer Test

9 Parameter Test

10 System Test

11 Printting Test

12 Beep


Remarks : ________________________________________________________


BM.0308.46/1


Equipment : Timbangan Date : _____________________

Merk : Precise Period : _____________________

Serial No. : _________________________ Room : _____________________

Kinerja

No Setting(gr) Terukur Toleransi (gr)1. 1 0,99-1,012. 2 1,98-2,023. 5 4,95-5,054. 10 9,9-10,15. 20 19,8-20,26. 50 49,5-50,57. 100 99-1018. 200 198-202

9. 500 495-50510. 1000 990-1010


Remarks : ___________________________________________________________


BM.0308.46/1


Equipment : Incubator Date : _____________________

Merk : Memmert Period : _____________________

Serial No. : _________________________ Room : _____________________

Kinerja

No Setting Suhu pada alat( C) Terukur Toleransi1. 37 36,63-37,372. 38 37,62-38,383. 60 59,4-60,6

Visual inspection Pass FailMain unit

AccessoriesCleaningFunction


Remarks : ___________________________________________________________


BM.0308.46/1

Biomedical. EngPreventive Maintenance Checklist Peruangan

Equipment : Tensimeter Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________

No ITEM KEADAAN NORMAL KONDISI KETERANGAN

1 Pengecekan Fisik Kondisi baik dan bersih, tidak ada lumut/jamur, dan segala kelengkapan nya ada semua (manset, balon pompa, air raksa, tubing spiral)

2 Pengecekan Manset Kondisi karet manset baik tidak ada kebocoran

3 Pengecekan tabung, Tabung dan glass

glass dan air raksa manometer baik sehingga air raksa tidak ada yang tumpah/ tetap menunjuk di angka 0 )

4 Pengecekan Balon Pompa

Balon pompa tidak ada kebocoran, elastisitasnya baik, pentil angin dan valve-nya baik

5 Pengecekan tekanan Air raksa naik saat dipompa sampai angka tertinggi dan saat didiamkan tidak turun secara cepat

Test Equipment used : D P M 3

Remarks : ___________________________________________________

Performed by : __________________ Verified : ____________________

BM 0308.46/1

Biomedical. Eng


Equipment : Bed Pan Washer Date : __________________

Merk : Stand bridge Period: __________________

Serial No. : _________________________ Room : __________________

NO Physical / Quantitative Test Pass Fail

1 Water Supply (cold and Hot)

2 Float Switch

3 Break Tanks

4 Pump

5 Timer

6 Heater

7 Probes, Sensor, Thermostats

8 Start Button

9 Key Switch

10 Door Micro switch

11 Door Mechanism/seal

12 Indicator Lights

13 Foot Bellows and Air Switch


Remarks : ________________________________________________________


BM 0308.46/1

Biomedical. Eng


Equipment : Matras Decubitus Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________

1. External cabinet and control panel in good condition.

______________

2. Pump.

______________

3. Quick disconnect coupling (tight, straight, not leaking)

______________

4. Power Cord (no cuts or exposed wire) and ______________

plug no (bent or missing pin)

5. Condition of Mattras -

______________

6. Indicator on/off

______________

Test Equipment Used : Tool set

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Phototherapy Lamp Date : __________________

Merk : Air-shields Period: __________________

Serial No. : _________________________ Room : __________________


1 Chassis/mounts/Fasteners

2 Controls/Switches

3 Fittings/Connectors


5 Timer

6 Indicator/Display

7 Cooling Fan

8 Bulb

9 Light output Check ……………… uw/cm2

10 Cleaning

Test Equipment Used : Phototherapy Radiometer

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Eagle Ten Sterilizer Date : __________________

Merk : Amsco Period: __________________

Serial No. : _________________________ Room : __________________


1 Preparation

2 Door Assembly

3 Selenoid Valve

4 Over temperature Controller

5 Air Vent (Steam)

6 Gauge

7 Chamber & Water Reservoir

8 Control Components

9 Final Test

Test Equipment Used : DPM III, Fluke Multimeter

Remarks : ________________________________________________________


BM.0308.46/1


Equipment : Baby Incubator Date : _____________

Merk : Air-Shields Period : _____________

Serial No. : ________________ Room : _____________

PPM CHECKLIST S/N Operational Checkout Procedure Pass Fail S/N Operational Checkout - Controller Pass Fail

1 Power Failure 1 Air Control Mode Of Operation 2 AC Power Cord 2 Air Set Temperature Alarm 3 VHA Stand 3 Air Auxiliary Probe 4 Hood Hinge and Latch operation 4 Baby Control Mode Of Operation 5 Access Panel Detent and Noise Level 5 Baby Set Temperature Alarm 6 Air Curtain Cover 6 Baby Temp Probe Fail Alarm 7 Main Deck 7 Air Flow Alarm 8 Iris Entry Port 8 Max Air Temperature 9 Access Panel Latches

10 Access Door Latch 11 Mattress Elevators 12 Mattress Tray Operation 13 Air Intake Micro filter 14 Oxygen Input Valve Filter 15 Air/Oxygen System


Remarks : ______________________________________________

Performed By:__________________ Verified By: __________________

BM.0308.46/1


Equipment : ECHO Date : __________________

Merk : GE Vivid 3 Period: __________________

Serial No. : Room : __________________

I. Physical ChecklistNo Item Pass Fail Description1 Table Console2 Probe Holders3 Control Panel4 Brake system5 Probe6 Monitor7 Cooling / Fans8 Keyboard Harness9 Power Cord10 Voltage Stabilizer11 Cover

12 Peripheral Input / output13 Printer

2. System Diagnostics ChecklistNo Item Pass Fail Description

1 Error Check2 Keyboard Function Check3 Color Monitor System Check4 Configuration Color Printer5 Calibration

Test Equipment Used : ______________________________________________

Remarks : ______________________________________________

Performed By:__________________ Verified By: ___________________

BM.0308.46/1


Equipment : USG Date : __________________

Merk : Periode : __________________

Serial No. : Room : __________________

I. Physical ChecklistNo Item Pass Fail Description1 Table Console2 Probe Holders3 Control Panel4 Brake system5 Probe6 Monitor7 Cooling / Fans8 Keyboard & Track Ball

9 Power Cord10 Voltage Stabilizer11 Cover12 Peripheral Input / output13 Printer

2. System Diagnostics ChecklistNo Item Pass Fail Description

1 Error Check2 Keyboard Function Check3 Color Monitor System Check4 Configuration Color Printer5 Calibration

Test Equipment Used : ______________________________________________

Remarks : ______________________________________________

Performed By:__________________ Verified By: ___________________

BM.0308.46/1

Biomedical. Eng


Equipment : Surgical Table Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________


1 Preparation

2 Hydraulic System

3 Casters and Floor Locks

4 Controls

5 Electrical Checks

6 Table Rigidity

7 Final Test

Test Equipment Used : Fluke Multimeter

Remarks : ________________________________________________________


BM 0308.46/1

Biomedical. Eng


Equipment : Obgyn Chair Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________


1 Preparation

2 Hydraulic System

3 Casters and Floor Locks

4 Controls

5 Electrical Checks

6 Chair Rigidity

7 Final Test


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : ENT Unit Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Warm Water System

7 Light System

8 Suction System

9 Mirror Warming

10 Compressed Air System

11 Stroboscope


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : SPIROMETER Date : __________________

Merk : ________________________ Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 AC-DC Adaptor

7 Transducer

8 Printer


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Dental Unit Date : __________________

Merk : Periode : __________________

Serial No. : ________________________ Room : __________________

NO Physical/Qualitative Test Pass Fail Description

1 Water Input Block

2 Air Input Block

3 Disinfection System

4 Drain

5 Hand Piece

6 Suction System

7 Amalgam Separator

8 Spittoon

9 Dental Chair Unit

10 Compresor Unit

11 Media

Voltages

Foot Control


Remarks : _____________________________________________________ _____________________________________________________

_____________________________________________________ _____________________________________________________

Performed by :_________________ Verified by :_________________

BM.0308.46/1

Biomedical. Eng


Equipment : STERILIZER Date : _________________

Merk : Iwaki Period : __________________

Serial No. : _________________________ Room : __________________


1 Preparation

2 Door Assembly

3 Solenoid Valve

4 Over temperature Controller

5 Air Vent (Steam)

6 Gauge

7 Chamber & Water Reservoir

8 Control Components

9 Final Test


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Cauter Date : __________________

Merk : Martin________________ Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Electrode

7 Foot Switch

8 Surgical Output

Test Equipment Used : ESU Analyzer, Fluke Multimeter

Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Infusion Pump Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________


1 Main Unit/Pole Clamp (any damage)

2 Battery Power

3 Self Check

4 Charging System

5 Start/Stop/Silence Operation

6Tube Clamp

7 Occlusion detection

8 Delivery Rate Accuracy

9 Air-in-line Sensor

10 Drop Sensor


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Syringe Pump Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________


1 Self Diagnosis

2 Dial

3 Clear Σml

4 Buzzer Volume

5 Body weight mode

6 Syringe size detection

7 Nearly empty alarm

8 Occlusion

9 Flow rate accuracy

10 Battery


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : THORACIC DRAINAGE Pump Date : __________________

Merk : GOMCO model 6020 Period : __________________

Serial No. : _________________________ Room : __________________

NO Physical / Qualitative Test Pass Fail Description

1 Pump Lubrication

2 Pump Cylinder

3 Solenoid Valve

4 Fan

5 Control Circuit

6 Collection Bottle and Cap Assembly

7 Manometer Tube Sterilization

8 Casing

9 Brake System

10

11


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : BREAST PUMP Date : __________________

Merk : MEDAP Period : __________________

Serial No. : _________________________ Room : __________________


1 Pump Lubrication

2 Pump Cylinder

3 Solenoid Valve

4 Pressure Regulator

5 Control Circuit



8 Casing

9 Brake System

10

11


Remarks : ________________________________________________________

Performed by : _____________________ Verified by : ______________________

BM.0308.46/1

Biomedical. Eng


Equipment : Liquid Oxygen Central Date :

__________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Liquid Tank

7 Safety Valve

8 Regulator System

9 Alarm System

10 Pressure Meter

11 Reserve Cyllinder


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Nitrous Oxide Central Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Cyllinder Connector

7 Safety Valve

8 Regulator System

9 Alarm System

10 Pressure Meter



Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Nitrogen Central Date :

__________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Cyllinder Connector

7 Safety Valve

8 Regulator System

9 Alarm System

10 Pressure Meter



Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Medical Air Equipment Date : __________________

Merk : ATLAS COPCO Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Reverse Cylinder

7 Safety Valve

8 Regulator System

9 Alarm System

10 Pressure Meter

11 Motor Compresstion

12 Oil Motor Compresstion

13 Filter Air


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Vaccum Equipment Date : __________________

Merk : Ohmeda Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Vaccum Machine

7 Safety Valve

8 Regulator System

9 Alarm System

10 Pressure Meter

11 Oil Mechine


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Anaesthetic Gas Scavenging Date :

__________________

System

Merk : Period : __________________

Serial No. : _________________________ Room : __________________






5 Indicator Display

6 Vaccum Machine

7 Alarm System


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Mixer Date :

Merk : __________________ Period : _______________

Serial No. : _________________________ Room : Laboratorium

NO Physical / Qualitative Test Pass Fail Keterangan

1 Motor



4 Line Indicator

Function test

Mixer Selector mode: FULL

TOUCH

Speed control : LOW

MEDIUM

HIGH

Test Equipment Used : Multi Meter, tool Set

Remarks : _____________________


BM.0308.46/1

Biomedical. Eng


Equipment : TONOMETER Date :

Merk : Period :

Serial No. : _________________________ Room : Eye Center


1 Chassis/Mounts/Fasteners

2 Controls/Switches



5 Indicator Display

6 Bulb

7 Lens

8 Subflex

9 Airpulse

10 Set/Reset

11 Review

12 Demo


Remarks : ________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Ultrasonic Biometer Date :

Merk : Period : __I_______________

Serial No. : ______________________ Room : Eye Centre



2 Controls/Switches


4 Cables/Accesories

5 Indicator/ Display

6 Probe

7 Light Pen

8 Foot Pedal

9 Test Piece

10 Printer

11 Setting Up The Software


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM 0308.64/1

Biomedical. Eng


Equipment : Injector Contras Date :

__________________ Merk :

_________________________ Period : __________________

Serial No. : _________________________ Room : __________________


1 Motor



4 Line Indicator

5 Function test

6 Display menu

7 Syringe System

8 Injection Selector mode: Single

Multi

9 Flow injector

10 Pressure Limit Injector

11 Delay system 12 Key pad13 Hand switch


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM 0308.64/1

Biomedical. Eng


Equipment : Retinal Camera Date :__________________

Merk : Period : I

Serial No. : _________________________ Room : Eye Center



2 Controls/Switches


4 Indicator/Display

5 Camera

6 CPU

7 Printer

8

9

10

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : OPERATING LAMP Date :__________________

Merk : _________________________ Periode :__________________

Serial No. : _________________________ Room :__________________


1 Chassis / Mounts/Fasteners

2 Power / Adaptor Voltage

3 Cables /Accessories

4 Dimmer Regulator System

5 Brake Rotary System

6 Focus System

7 Cleaning


Remarks : ________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : MICROSCOPE Date :__________________

Merk/Type : _________________________ Periode :__________________

Serial No. : _________________________ Room :__________________



2 Power / Line Indicator


4 Dimmer System

5 Bulb Lamp

6 Focus System

7 LENS Cleaning

8 Balancing

Test Equipment Used : Alcohol ,tool set

Remarks : ________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________


BM.0308.46/1


Equipment : Surgical Table Date :______________________

Merk : Amsco/2080 Manual Period : _____________________

Serial No. : _________________________ Room : _____________________

PPM Check ListS/N Physical/Qualitative test Pass Fail S/N Pass Fail

1 Supported Table Top 8 Drive Crank Clutch Adjustment a. With base cover raised 9 Side Tilt Adjustment b. When base cover is not Raised 10 Selector Handle Locating Adjustme-

2 Floor Locks Ment a. Floor locks improperly adjusted 11 Friction Device on Lift Cylinder b.Binding of pedal linkage Adjustment c.Insufficient clearance between pedal 12 Kidney Elevator Handle And floor 13 Lateral Movement Stop Pin Adjus d.Pedal Sticks in Up Position Ment e.Pedal not Return To Maximum Up 14 Tredelenburg Hand Crank Position 15 Lateral Tilt Mechanism

3 Pump Pedal Adjustment 16 ShiftLever Modification 4 Hydraulic System 17 Lubrication

a.Oil Level b.Strainer c.Hydraulic Leakage

5 Table Elevation 6 Table Top Positioning 7 Lift Carriage Adjustment

Test Equipment Used : Multimeter, Tool Set

Remarks : ___________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : WARMING CABINET Date :__________________

Merk/Type : AMSCO Periode :__________________

Serial No. : _________________________ Room : ___________________



2 Power / Line Indicator


4 Heating Filament

5 Fan

6 Door Sensor

7 Display

8 Clean Cabinet

9 Heat Sensor


Remarks : ________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Oxygen Transfer Date :

Merk : Merk :

Serial No. : _________________________ Room : __________________



2 Fitting/connector

3 Regulator

4 Pressure meter

5 Pipe


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Scrub Station Date : ________________________

Merk : Amsco Period : ________________________

Serial No. : Room : ________________________



2 Goose Neck/Rose Spray

3 Soap Spout

4 Hot Water

5 Cold Water

6 Timer

7 Soap Container

8 Temperature selector Handle

9 Water Knee Panel

10 Soap Knee Panel

11 Drain

12 Lubrication

Test Equipment Used : Multi Meter, tool Set, DPM III

Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Campimeter Date : ________________________

Merk : Humprey Period : ________________________

Serial No. : Room : ________________________

No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik

1. Badan /Permukaan2. Kabel/Konektor3. Saklar/Indicator4. Printer,key board,mouse5. Monitor6. Lampu 7. Filter Udara8. System self Cek9. System LOG10. Tegangan AC 220V

Test Equipment Used : Multi Meter, tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Tourniquet System Date : _________________

Merk : zimmer Period : _________________

Serial No. : Room : __________________


1 Cleaning

2 Inspection

3 Functional and Calibration Checks

4 Calibration:

Transducer Offset

Common Mode

Span Adjustment

Iteration Of Adjustment

5 Watchdog Timer Test

6 Leak Testing

7 Power Supply/ Battery Charger

8Battery Voltage Check and Battery Service

9 Overpressure Regulator


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment :Cam Vision Stimulator Date : ________________________

Merk : Period : ________________________

Serial No. : Room : ________________________


1. Badan /Permukaan2. Kabel/Konektor3. Saklar/Indicator4. SLIDE Simulator5. Motor


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Cromoganic Kinetic SYS.Date :

________________________ Merk : Helena

Laboratories Period : ________________________

Serial No. : Room : Laboratorium


1. Badan /Permukaan2. Kabel/Konektor3. Saklar/Indicator4. Monitor5. Printer6. Unit7. Key Board8. Lampu 9. Filter Udara10. Pipet

Test Equipment Used : Multi Meter, tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Oxygen Flow meter Date : ________________________

Merk : Ohmeda/CIG Period : ________________________

Serial No. : Room : ________________________


1. Bola penunjuk2. Regulator 3. Botol Humidifier4. Volume output Pengukuran Terukur Toleransi

1 Lpm 0,95-1,052 Lpm 1,9-2,13 Lpm 2,85-3.154 Lpm 3,8-4,25 Lpm 4,75-5,2510 Lpm 9,5-10,515 Lpm 14,25-15,75

Test Equipment Used : Multi Meter, RT-200 Cal Analyzer,tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Suction Regulator Date : ________________________

Merk : Ohmeda Period : ________________________

Serial No. : Room : ________________________


1. Saklar On/off2. Regulator 3. Jarum /meter penunjuk4. Suction output Pengukuran Terukur Toleransi

- 100 mmHg 95-105- 200 mmHg 190-210- 300 mmHg 285-315- 400 mmHg 380-420- 500 mmHg 475-525- 600 mmHg 570-630- 700 mmHg 665-735

Test Equipment Used : Multi Meter, DPM III,tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng



Merk : Ohmeda/ Thoracic Period : ________________________

Serial No. : Room : ________________________


1. Saklar On/off2. Regulator 3. Jarum /meter penunjuk4. Suction output Pengukuran Terukur

5 cmH2O 15 cmH2O 25 cmH2O 40 cmH2O 50 cmH2O 60 cmH2O Full Vac

Test Equipment Used : Multi Meter, RT 200,tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng



Merk : Ohmeda Period : ________________________

Serial No. : Room : ________________________


1. Saklar On/off2. Regulator 3. Jarum /meter penunjuk4. Suction output Pengukuran Terukur Toleransi

- 20 mmHg 19-21- 60 mmHg 57-63- 80 mmHg 76-84- 120 mmHg 114-126- 160 mmHg 152-168- 200 mmHg 190-210

Full Vac

Test Equipment Used : Multi Meter, DPM III,tool Set

Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Autorefraktometer Date : ________________

Merk : Period : _________________

Serial No. : Room : __________________


1 Chassis / Mounts

2 Control / Switch

3 Fitting / Connector

4 Cable / Accessories


6 Printer


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Performed by : _____________________ Verified by : ____________________

BM.0308.46/1

Biomedical. Eng


Equipment : Head Lamp Date :

_________________ Merk :

Period : _________________

Serial No. : Room : __________________


1 Chassis / Mounts

2 Control / Switch




6 Lamp


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : PHOROPTOR Date : _________________

Merk : Period : _________________

Serial No. : Room : _________________


1 Chassis / Mounts

2 Control / Switch




6 Lamp


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Rehab Chair Date :__________________

Merk : Sinwanai Period :

Serial No. : _________________________ Room :



2 Controls/Switches


4 Cables/accessories

5 Indicator/Display

6 Timer

7 Over loud

8 Speed adjusted

9 Motor

10

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Traction Machine Date :__________________

Merk : Triton Period :__________________

Serial No. : _________________________ Room :__________________



2 Controls/Switches



5 Indicator/Display

6 Timer

7 Belt/Suspension

8 Patient Switch Activated

9 Static /Intermittent

10 Traction Progress

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Rigidometer Date :__________________

Merk : Uroan Period :__________________

Serial No. : _________________________ Room :__________________



2 Controls/Switches



5 Indicator/Display

6 Sensor

7 Electric Charge

8 Battery

9 Computer Unit

10

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Ultrasound Therapy Date :__________________

Merk : Period :__________________

Serial No. : _________________________ Room :__________________


1 Power Cord

2 Fuse Drawer

3 Folding Handle

4 Power/Intensity Key

5 Output Calibration Key

6 Transducer Data Key

7 Transducer Head

8 Contrast Display

9 Transducer Cable

10 Cleaning Unit

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : EEG Date :__________________

Merk : Period :__________________

Serial No. : _________________________ Room :__________________


1 Overview

2 Power

3 Input Circuit and Amplifier

4 Operation

5 Activation

6 Disk Drive

7 Electrode Lead

8 Hard Disk and MO

9 Printer

10

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Tympanometer Date :__________________

Merk : Period :__________________

Serial No. : _________________________ Room :__________________


1 Display

2 Daily Calibration

3 Biological Calibration

4 Eartips

5 Probe TIP/Probe Head

6 Probe Lights

7 Probe Handle

8 Printer

9 Test Sequence

10

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Nebulizer Date :__________________

Merk : Period :__________________

Serial No. : _________________________ Room :__________________



2 Power line


4 Ultrasonic Electrode

5 Timer

6 Sensor Water Level

7 Air Filter

8 Fan

9 Cleaning

10

11

12


Remarks : ________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM 0308.64/1

Biomedical. Eng


Equipment : FILM SCREEN Date :__________________

Merk : _________________________ Period :__________________

Serial No. : _________________________ Room :__________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Bulb

7 Film Roller

8 Forward & Reverse System

9 Cover


Remarks : ________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM 0308.64/1

Biomedical. Eng


Equipment : Washer Date :__________________

Merk : Period :__________________

Serial No. : _________________________ Room :__________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Water Supply

7 Air Supply

8 Drain System


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Light Source Date :__________________

Merk : _________________________ Period :__________________

Serial No. : _________________________ Room :__________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Bulb

7 Fiber Optic

Test Equipment Used : Multi Meter, Tool Set, DPM III

Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Steam Boiler Date :__________________

Merk : AMSCO Period :__________________

Serial No. : _________________________ Room :__________________


1 Cable/Accessories

2 Pressure Steam

3 Connecting Pipe

4 Cold Water Inlet

5 Hot Water Inlet

6 Glass Level

7 Water Pump

8 Water Sensor Level

9 Heater

10 Check Valve

11 Drain

12 Pressure Meter

13 Safety Valve

Test Equipment Used : Fluke Multimeter, Tool Set

Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : OPTOTIF PROYEKTOR Date : _________________

Merk : Period : _________________

Serial No. : Room : _________________


1 Chassis / Mounts

2 Control / Switch




6 Lamp


Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Auto Fluid Balance Monitor Date

:__________________ Merk : Aquarius

Period :__________________

Serial No. : _________________________ Room :_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Self Test

7 Alarm signal

8 Heater

9 Battery

Test Equipment Used : Multi Meter, Tool Set, DPM III

Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Patient Warming System Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Power/Line Indikator

3 Cable/Accessories

4 Heating Filament

5 Fan

6 Door Sensor

7 Display

8 Clean Cabinet

9 Heat Sensor

Test Equipment Used : ______________________________________________________________

Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Cast Cutter Date :__________________

Merk : Stryker Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Motor

7 Vacum


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Paracare Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Heater/Temperatur


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Intelect Advanced Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indikator/Display

6 Pad Elektrode

7 Intensity


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Blood Warmer Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Heater

7 Line Of Tubing Set


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Laser Argon Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Colling System

7 Laser Output


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Laser YAG Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Laser Output


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Static Bike Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Tilt Table Lifeline Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Motor/Hydraulic System

7 Lubricating


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : CPM Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Drying Cabinet Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Fan

7 Heater

8 Cleaning


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : ID Camera Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room :_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Lamp

7 Motor

8 Cleaning


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Water Filter Amway Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room :_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Lamp UV

7 Filter

8 Cleaning


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Cassette Autoclave Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room :_________________


1 Control/Switches

2 Fitting/Connector

3 Cable/Accessories

4 Indicator/Display

5 Cleaning

6 Air Filter

7 Cassette

8 Reservoir

9 Wash Bottle

10 Lubricating/Changing Cassette seal

11 Temperature

12 Aluminium Antena & Holder

Test equipment used :.._____________________

Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : EMG Date :__________________

Merk : Period :__________________

Serial No. : _________________________ Room :__________________


1 Overview

2 Power

3 Input Circuit and Amplifier

4 Operation

5 Activation

6 Disk Drive

7 Electrode Lead

8 Hard Disk

9 Printer

10

11

12


Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Bilirubinometer Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room :_________________



2 Power/Line Indikator


4 Bulb Lamp

5 Cleaning


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Blood Bank Date :__________________

Merk : Sanyo Period :__________________

Serial No. : ______________________ Room :_________________



2 Controls/Switches

3 Fitting/Connector

4 Indikator/Display

5 Cable/Accessories

6 Temperature

7 Freezer


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Centrifuge Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room :_________________




3 Indicator/Display

4 Speed

5 Start Botton

6 Stop Botton

7 Lid Botton

8 Timer

9 Decelerate Botton

10 Door Switch

11 Imbalance


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Ultrasonic Cleaner Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room :_________________




3 Power/Adaptor

4 Rack system

5 Indikator

6 Timer

7 Cleaning

8

9

10

11


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Oxicom Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room :_________________





4 Control/Switches

5 Indikator display

6 Sensor

7

8

9

10

11


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Unit Endoscopy Date :__________________

Merk : OLYMPUS Period :__________________

Serial No. : ______________________ Room :_________________


1 Control / switch

2 Fitting and connectors

3 Cable and accessories

4 Indicator / display

5 Suction System

6 Xenon lamp

7 Gastro scope

8 Colon scope

9 Broncos scope

10 Printer

11 White Balance

12 Monitor


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Polymerization Light Date :__________________

( Light Curing )

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________


1 Chassis / Mount / Fasteners

2 Control / Switches




6 Hand Piece

7 Lamp


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Infant Warmer Date :__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________







6 Probe

7 Heater

8 Suction System

9 Flow meter O2

10 Bassinet Tilt Control

11 Side and End Panel

12 X-Ray Tray

13 Examination light


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Short Wave Diathermy Date

:__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________


1 Power cord

2 Fuse drawer

3 Power output meter

4 Power adjust step

5 Electrode

6 Electrode cable

7 Timer + indicator

8 Electrode holding

9 Wheel + Brake

10

11

12

13


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Microwave Diathermy Date :__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________


1 Power cord

2 Fuse drawer

3 Power output meter

4 Power adjust step

5 Electrode

6 Electrode cable

7 Timer + indicator

8 Electrode holding

9 Wheel + Brake

10

11

12

13


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Electric Stimulator Date :__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________







6 Brake system

7 Vacuum System

8 Pad electrode

9 Water reservoir

10 Intensity

11

12

13


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Infra Red Lamp Date :__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________







6 Timer

7 Lamp

8

9

10

11

12

13


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Cusa Unit Date :__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________







6 Pump Irrigation

7 Suction

8

9

10

11

12

13


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Bor Tulang Date

:__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________



2 Power Line Indicator


4 Accessories

5 Gas Supply

6 Motor System

7 Drill Rotating

8

9

10

11

12

13


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Electronic Laparofator Date

:__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________





4 Accessories

5 Gas Supply

6

7

8

9

10

11

12

13


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Nerve Detector Date :__________________

Merk : ______________________ Period :__________________

Serial No. : ______________________ Room :_________________





4 Accessories

5 Battery

6

7

8

9

10

11

12

13


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Suction Pump Unit Date : __________________

Merk : Period : __________________

Serial No. : _________________________ Room : __________________


1 Pump Lubrication

2 Pump Cylinder

3 Valve

4 Regulator

5 Control Circuit



8 Casing

9 Brake System


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : SPIROMETRI Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________






5 Battery / Charger



8 Tranduser

9 Cabel + Conector Tranduser

10 Beep

11 Calibrasi


Remarks : ________________________________________________________


BM 0308.4

Biomedical. Eng


Equipment : Cell Dyn 3500 Date :__________________

Merk : Abbott Period :__________________

Serial No. : ______________________ Room :_________________





4 Control/Switches

5 Indikator display

6 Tubings

7 Valve


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Axsym System Date :__________________

Merk : Abbott Period :__________________

Serial No. : ______________________ Room :__________________





4 Control/Switches

5 Indicator/ display

6 Monitor

7 Printer


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Bactec Date :__________________

Merk : Becton Dickinson Period :__________________

Serial No. : ______________________ Room :__________________





4 Control/Switches

5 Indikator display

6 Heater


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : ENTONOX Date :__________________

Merk : Jono Mark II Period :__________________

Serial No. : ______________________ Room :__________________




3 Oxygen Accessories

4 Nitrous Oxide Accessories

5 Mixer (%)

6 Test Lung


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Heart Lung Machine Date : __________________

Merk : Stockert S3 Period : __________________

Serial No. : _________________________ Room : __________________



2 Controls/Switches

3 Fiitings/Connectors


5 Battery/Charger

6 Indicator/Display

7 Alarms/Audible Signals

8 Pump

9 Pressure Meter

10 Power Suplay Voltage (5 V, 12 V, 15 V dan 24 V)


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Anaesthetic Machine Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________



2 Controls/Switches



5 Battery/Charger

6 Indicator/Display

7 Gas Supply

8 Bellows Rubber

9 Pressure Meter

10 Gas Monitoring System


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : IABP Date

:__________________ Merk : Datascope

Period :__________________

Serial No. : ______________________ Room :__________________


1 Cords and Cables

2 Controls and Switches

3 Safety Disk

4 Cooling Fan

5 Doppler

6 Pneumatic Compartment

7 Fill Assembly

8 Motor Compartment

9 Electronic Panel

10 Helium Supply

11 Battery Back Up

12Calibrate System and Perform Functional Test


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Oximeter Date : __________________

Merk : _________________________ Period : __________________

Serial No. : _________________________ Room : __________________



2 Controls/Switches



5 Battery/Charger

6 Indicator/Display

7 SPO2 Sensor


Remarks : ________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : CPAP Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Doctor Operating Chair Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________


1 Preparation

2 Hydraulic System

3 Caster and Floor Locks

4 Controls

5 Electrical Checks

6 Chair Rigidity

7 Final Test

8

9


Remarks : ______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Slit Lamp Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Lamp


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Dental X-Ray Date :__________________

Merk : Period :__________________

Serial No. : _______________________ Room :__________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Lubrication Rel Up/Down

7 Mechanical Checks

8 Cleaning

9 Functional Checks

Setting Pada Alat Terukur Koreksi

KVp Second KVp Second KVp Second


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Uroflow

Merk : Date :__________________

Serial No. : ______________________ Room:_________________



2 Control/Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/Display

6 Volume Transducer

7 Printer

8 Measurement cup


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : AUDIOMETER Date :__________________

Merk : Period :__________________

Serial No. : _______________________ Room :__________________

PPM Check List PPM Check ListS/N Physical/qualitative test Pas

sFail S/N Pas

sFail

1 Power on/off 18 LED Read Out of Frequency Selected2 Present/Interrupt Switch (2) 19 LED Read Out Of Intensity Selected3 Left/Right Earphone Selector 20 LED Indicator (subject Respond)4 Stimulus on (interrupt) 21 LED Indicator (Stimulus Present)

Stimulus off (Present) 22 LED Indicator of Active Test 5 Automatic Pulsing Earphone or Masking For Bone6 Frequenchy Modulation (FM) 23 LED indicator Stimulus On/Off7 Test Signal 24 LED Idicator of Auto Pulsign8 + 10 dB Switch 25 LED Indicator for FM9 Tone Stimulus Select 26 LED indicator for masking level

10 Tape/Microphone Select intensity11 Speaker Select 27 LED indicator of +10 dB12 + 2.5 Select 28 LED Indicator Earphone/Bone13 Talk Forward 29 LED Indicator of +2.5 dB14 Frequency Select Control

Doal30 LED Indicator Speaker Selectionu

15 Intensity Control Dial 31 LEDIndicator of Tone Stimulus

16 Masking Level Control 32 LED Indicator of Tape or 17 Test Microphone Level

ControlMicrophone Stimulus Selected

33 Speech Level VU meter


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng

LAPORAN PEMERIKSAAN ALAT BARU

Equipment : Mesin Hemodialisa

Merk : Date :__________________

Serial No. : ______________________ Room:_________________


1 Working Hours

2 Flow 300 (Dialisis)



5 Blood Leak

6 Dimnes

7 Blood Pump Rate

8 Check Temperature


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Resuscitator Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Fibrintimer Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Rotator Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Water Bath Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6 Temperature

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Thermasealerr Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Retraction Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Histocantre Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Croytom Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Chiller Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________

Physical / Qualitative Test Pass Fail

NO Description


2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Lemari Asam Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment :Thermasealler Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment :Cryotome Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment : Clinitex Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment :Radrometer Date

:__________________ Merk :

Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

Biomedical. Eng


Equipment :Architect Date :__________________

Merk : Period :__________________

Serial No. : ______________________ Room:_________________



2 Control/ Switches

3 Fitting/Connector

4 Cable/Accessories

5 Indicator/display

6

7

8

9


Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


BM.0308.46/1

cek list biomedic

Documents

rack assembly

squeegee assembly

turnaround assembly

display housing

rewet rollers

radiologi film guide

computer module housing

rear of display