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New
Equipment Acceptance Checklist
Facility
Name: _______________________________________________________________________________
Address: ___________________________________________________________________________________
*
Note to Salesmen or Company Rep, Regarding your Quote
or Bid;
This Equipment Acceptance Checklist must be returned
for review before a P.O. can be issued.
Return to:
Attention ______________________ .
For any additional information, please call: ___________________________
1.
Equipment:
Equipment
Type: _________________________________________________________________________
Equipment
Model Number: ______________________________ SN:
_______________________________
Is
this Device / Equipment accredited? ____Yes ____No
This
Equipment is: ____New ____Used ____Reconditioned
____Refurbished
2. Manufacturer:
Manufacturer
of Equipment: __________________________________
Subsidiary of: __________________
Address
(for parts, repair, tech support, etc.) : _________________________________________________
________________________________________________________________________________________
Phone
Numbers: _____________________________________________________
Fax: ________________
3. Secondary Service Rep:
Name:
______________________________________________________
Name
of Service Supervisor: __________________________
Phone Numbers: _______________________
4. Equipment Details:
The
Device is powered by: ____Battery, ____A.C. Power,
____A.C. to D.C. Power
•
If Battery, is battery Included? ____Yes ____No
If No, cost and supplier of Battery
is: $________ /____________________________________________
•
If A.C. powered, does the device have a hospital
grade plug? ____Yes ____No
If
No, is the system double insulated? ____Yes ____No
•
If D.C. powered, is the power supply included? ____Yes
____No
Does
the device meet AAMI electrical leakage current
specifications? ____Yes ____No
State
number, size and type of fuses: _________________________________________________________
Is
the device susceptible to R.F. electromagnetic fields?
____Yes ____No
•
If yes, please describe: _______________________________________________________________
_____________________________________________________________________________________
Does
this device require any special connectors? ____Yes
____No
•
If yes, are they supplied with device?____Yes ____No
If no, cost
and supplier’s name: $_________ / ________________________
Phone: _______________
Are
there any special services or equipment needed for
up-keep and or PM for this device? ___Yes ___No
•
If yes, please list item number and cost: (If
list is long, attach a list of all, probes, cables,
etc.
needed for proper
operation and
or P.M. / calibration, along with name and address
of manufacturer.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Are
there any needed modifications to premises? ____Yes
____No
•
If yes, please list:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Are
there any special brackets or mounting hardware required?
____Yes ____No
•
If yes, specify cost & part #’s:
$__________
/ _____________________ $_________
/ _________________________
$__________
/ _____________________ $_________
/ _________________________
$__________
/ _____________________ $_________
/ _________________________
Are
active replacement components obtainable locally or
through other sources? ____Yes ____No
•
If yes, list components and supplier with current
phone numbers: __________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Total
weight as shipped: _________________
Service
Contract available for system? ____Yes ____No
Type
of Warranty: ____Bumper to Bumper type, ____ Parts
Only, ____Parts and Labor, ____Labor.
Warranty
period: ____90 Day, ____6 Months, ____One year, ____Two
Year, ____Other: __________________
Warranty
starts: ____Upon arrival at Facility, ____After acceptance
testing, ____After setup by Mfg Rep.
Are
parts and service time included in warranty? ____Yes
____No
•
If no, specify: ___________________________________________________________________________
Are
preventative maintenance inspections included in warranty
period? ____Yes ____No
•
If yes, how many? ___________
•
If no, are P.M.s’ required?____Yes ____No
If yes, how often?
_______________
Are
two copies of the User Operator Manual and one copy
of the Service Manual included? ____Yes ____No
•
If no, explain: ____________________________________________________________________________
_________________________________________________________________________________________
Cost
of additional Manuals: * $____________
*
This Facility will not accept Medical Equipment
without comprehensive User Operator & repair manuals,
unless
othe rarrangements have been made prior to issue of
P.O. number!
5. Service. (During Warranty period!)
Hours
of Service: ____8 h’s/ 5 days, ____8
h's / 6 days, ____12
h's / 5 days,
____24
h's / 5 days, ____24 h's / 7 days,
____Other: _________________
Is
phone support available? ___________
•
If yes, please list phone numbers:_________________________________________________________
______________________________________________________________________________________
Is
phone support : ____Immediate, ____Call-Back.
If
Call-Back, how long does it take for support to return
a problem call: *_____________________________
*
Most Clinical Engineers / Bio-Meds, are seldom
in one place for any length of time. Playing phone
tag consumes
man-hours
and
can be a contributing factor in wasting earnable revenues
on patient related Equipment!
Service
response time: _______________
Is
on-call service available? ____Yes ____No On-site?
____Yes ____No
Are
loaner devices available, under the warranty period?____Yes
____No Non-warranty?
____Yes ____No
•
If no, specify cost of said same, per day, per week,
per mo.? ____________________________________
_______________________________________________________________________________________
Is
on-site operator training included?
•
If no, give cost of said same: ____________________________________________
Cost
of refresher training: $_______________On-site, $______________Off-site.
6. Clinical Engineer / Medical Electronics.
Is
Factory service training included in purchase ? ____Yes
____No
• If
no, specify cost: $__________________
On-site
training? ____Yes ____No Off-site?
____Yes ____No
Are
any hazardous chemicals included, produced ,and or,
as a result of the operation of this device?
____Yes
____No
•
If yes, include MSDS copy: Specify spillage hazard:
__________________________________________________________________________________________
__________________________________________________________________________________________
If this is a large piece of equipment, (over
sixty (160) pounds,) a room layout is NEEDED.
Please
include a copy with this check list of equipment
dimensions and any other needs, i.e. water hook-up,
air , etc :!
Name and position of person(s) performing the completion
of this acceptance check list / Reference Bid or
Quote Number:
_______________________________________________________________________________________
_______________________________________________________________________________________
Please staple or tape your business card here:
Please return to : Attn: _____________________Department.
For any additional information pertaining to this
document, contact:_____________________________________________
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