Preventive Maintenance Checklist: Biomedical. Eng

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 the
Following :
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 and
Associated 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.
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 belt
Cleaning
___ use anti septic cleaner on the following areas: ___ Handrails ___ Shroud ____ Walking belt
Power 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 test
Ground wire leakage to ground (100 uA max) Open Closed
Chassis 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 ohm
Environment
Room temperature_____(C) Humidity_____%
Operational Test
Apply 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 the
Following :
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 and
Associated 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.
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.
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 : 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 500A 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. Eng
Equipment : Ventilator Date : _____________________

Merk : _________________________ Period : _____________________
Serial No. : _________________________ Room : _____________________
PPM CHECKLIST S/N Calibration/ Verification checklist Pass Fail

S/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/
Biomedical. Eng
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
Biomedical. Eng
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
Biomedical. Eng
Equipment : Timbangan Date : _____________________

Merk : Precise Period : _____________________
Serial No. : _________________________ Room : _____________________
Kinerja
No Setting(gr) Terukur Toleransi (gr)

1. 1 0,99-1,01
2. 2 1,98-2,02
3. 5 4,95-5,05
4. 10 9,9-10,1
5. 20 19,8-20,2
6. 50 49,5-50,5
7. 100 99-101
8. 200 198-202
9. 500 495-505
10. 1000 990-1010
Remarks : ___________________________________________________________
BM.0308.46/1
Biomedical. Eng
Equipment : Incubator Date : _____________________

Merk : Memmert Period : _____________________
Serial No. : _________________________ Room : _____________________
Kinerja
No Setting Suhu pada alat( C) Terukur Toleransi

1. 37 36,63-37,37
2. 38 37,62-38,38
3. 60 59,4-60,6
Visual inspection Pass Fail
Main unit
Accessories
Cleaning
Function
Remarks : ___________________________________________________________
BM.0308.46/1
Biomedical. Eng
Preventive 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 Balon pompa tidak ada
Pompa 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
Biomedical. Eng
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
Biomedical. Eng
Equipment : ECHO Date : __________________

Merk : GE Vivid 3 Period : __________________
Serial No. : Room : __________________
I. Physical Checklist
No Item Pass Fail Description
1 Table Console
2 Probe Holders
3 Control Panel
4 Brake system
5 Probe
6 Monitor
7 Cooling / Fans
8 Keyboard Harness
9 Power Cord
10 Voltage Stabilizer
11 Cover
12 Peripheral Input / output
13 Printer
2. System Diagnostics Checklist

1 Error Check
2 Keyboard Function Check
3 Color Monitor System Check
4 Configuration Color Printer
5 Calibration
Test Equipment Used : ______________________________________________
Remarks : ______________________________________________
Performed By:__________________ Verified By: ___________________
BM.0308.46/1
Biomedical. Eng
Equipment : USG Date : __________________

Merk : Periode : __________________
Serial No. : Room : __________________
I. Physical Checklist
1 Table Console
2 Probe Holders
3 Control Panel
4 Brake system
5 Probe
6 Monitor
7 Cooling / Fans
8 Keyboard & Track Ball
9 Power Cord
10 Voltage Stabilizer
11 Cover
12 Peripheral Input / output
13 Printer
2. System Diagnostics Checklist

1 Error Check
2 Keyboard Function Check
3 Color Monitor System Check
4 Configuration Color Printer
5 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
Tube Clamp
6
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 : ________________________________________________________
Performed by :
_____________________
Verified by : _______________________
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 pad
13 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
Biomedical. Eng
Equipment : Surgical Table Date :______________________

Merk : Amsco/2080 Manual Period : _____________________
Serial No. : _________________________ Room : _____________________
PPM Check List

S/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 /Permukaan
2. Kabel/Konektor
3. Saklar/Indicator
4. Printer,key board,mouse
5. Monitor
6. Lampu
7. Filter Udara
8. System self Cek
9. System LOG
10. Tegangan AC 220V

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
Battery Voltage Check and Battery
8 Service
9 Overpressure Regulator
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
BM.0308.46/1
Biomedical. Eng

Equipment :Cam Vision Stimulator Date : ________________________
Merk : Period : ________________________
Serial No. : Room : ________________________

1. Badan /Permukaan
2. Kabel/Konektor
3. Saklar/Indicator
4. SLIDE Simulator
5. Motor
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
BM.0308.46/1
Biomedical. Eng

Equipment : Cromoganic Kinetic SYS.Date : ________________________
Merk : Helena Laboratories Period : ________________________
Serial No. : Room : Laboratorium

1. Badan /Permukaan
2. Kabel/Konektor
3. Saklar/Indicator
4. Monitor
5. Printer
6. Unit
7. Key Board
8. Lampu
9. Filter Udara
10. Pipet

Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
BM.0308.46/1
Biomedical. Eng

Equipment : Oxygen Flow meter Date : ________________________
Merk : Ohmeda/CIG Period : ________________________
Serial No. : Room : ________________________

1. Bola penunjuk
2. Regulator
3. Botol Humidifier
4. Volume output Pengukuran Terukur Toleransi
1 Lpm 0,95-1,05
2 Lpm 1,9-2,1
3 Lpm 2,85-3.15
4 Lpm 3,8-4,2
5 Lpm 4,75-5,25
10 Lpm 9,5-10,5
15 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/off
2. Regulator
3. Jarum /meter penunjuk
4. 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/off
2. Regulator
4. 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/off
2. Regulator
4. 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
Calibrate System and Perform
12 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 :_________________
Physical / Qualitative Test Pass Fail

Description
NO
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 List
S/N Physical/qualitative test Pass Fail S/N Pass Fail

1 Power on/off 18 LED Read Out of Frequency Selected
2 Present/Interrupt Switch (2) 19 LED Read Out Of Intensity Selected
3 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 Bone
6 Frequenchy Modulation (FM) 23 LED indicator Stimulus On/Off
7 Test Signal 24 LED Idicator of Auto Pulsign
8 + 10 dB Switch 25 LED Indicator for FM
9 Tone Stimulus Select 26 LED indicator for masking level
10 Tape/Microphone Select intensity
11 Speaker Select 27 LED indicator of +10 dB
12 + 2.5 Select 28 LED Indicator Earphone/Bone
13 Talk Forward 29 LED Indicator of +2.5 dB
14 Frequency Select Control Doal 30 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 Control Microphone 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 :_________________

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

Preventive Maintenance Checklist: Biomedical. Eng

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Preventive Maintenance Checklist: Biomedical. Eng

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Biomedical.

Preventive Maintenance Checklist

Equipment : Mac. Lab. Monitoring Date : __________________

Display housing ___________________________________

Computer module housing ___________________________________

Line / Power plug ___________________________________

Line / Power cord ___________________________________

Display fuse holder ___________________________________

System cables at rear of Display & ___________________________________

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

Performed by : _____________________ Verified by : _______________________

Preventive Maintenance Checklist

Equipment :PROCCESING FILM Date : __________________

 Film Guide Assembly ____________________________________

 Detector/Crossover Assemblies ____________________________________

 Squeegee Assembly ____________________________________

 Rack Assembly ____________________________________

 Turnaround Assembly ____________________________________

 Recirculation System ___________________________________

 Developer Temperature ___________________________________

 Water Flow to the Processor ___________________________________

 Chemical Replenisher ___________________________________

 Strainer Assembly ___________________________________

 Dryer Section ___________________________________

Test Equipment Used : ________________________________________________________

Performed by : _____________________ Verified by : _______________________

Preventive Maintenance Checklist

Equipment : Electrocardiograph Date : __________________

Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meter

Performed by : _____________________ Verified by : _______________________

Preventive Maintenance Checklist

Equipment : Treadmill Date : __________________

Performed by : _____________________ Verified by : _______________________

LAPORAN PEMERIKSAAN ALAT BARU

Equipment : PATIENT MONITOR

Display housing ___________________________________

Computer module housing ___________________________________

Line / Power plug ___________________________________

Line / Power cord ___________________________________

Display fuse holder ___________________________________

System cables at rear of Display & ___________________________________

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 ___________________________________

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : __

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___

Performed by : _ Verified by : ___