Cek List Biomedic

Biomedical.
Eng
Preventive Maintenance Checklist

Equipment
: Mac. Lab. Monitoring
Date
: __________________
Merk
: MARQUET
Period
: __________________
Serial No.
: _________________________
Room
: __________________
Display housing
___________________________________
Computer module housing
___________________________________
Line / Power plug
___________________________________
Line / Power cord
___________________________________
Display fuse holder
___________________________________
System cables at rear of Display &

Computer Module
___________________________________
Cable connectors
___________________________________
Rack & Parameter Module connectors

___________________________________
Labeling and accessories
___________________________________
Patient safety checks
___________________________________
Indicators on / off and screen
___________________________________
LEDs on the parameter Module
___________________________________
Display performance
___________________________________
Visual and audible Alarm
___________________________________
Self-check procedures
___________________________________
Test Equipment Used
: ECG Stimulator BIOTEK, Fluke multi meter
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
:PROCCESING FILM
Date
: __________________
Merk
:KODAK
Period
: __________________
Serial No.
: _________________________
Room
: RADIOLOGI
Film Guide Assembly
____________________________________
Detector/Crossover Assemblies
____________________________________
Rollers
Gears
Guide Shoes
Bearings
Brackets
Nuts
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Squeegee Assembly
____________________________________
Rollers
Gears
Guide Shoes
Bearings
Brackets
Nuts
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Rack Assembly
____________________________________
Rollers
Sprockets
____________________________________
____________________________________
Chain
Springs
Rewet Rollers
Turnaround Assembly
Rollers
Tubing
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Main Drive Assembly
___________________________________
___________________________________
Plumbing
___________________________________
Connections
Tubing
Recirculation System
Filter
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Developer Temperature
___________________________________
___________________________________
Water Flow to the Processor
___________________________________
___________________________________
Chemical Replenisher
___________________________________
___________________________________
Strainer Assembly
___________________________________
___________________________________
Dryer Section
___________________________________
Bearing
Air Tube
Roller
O-Rings
Dryer Temperature
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Electrocardiograph
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
Visual Inspection :
L
Disconnect the cardiograph form AC power and inspect for the

Following :
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 :
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
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
+5 V dc ( 0,5) ____ Volts
+16,5 V dc ( 1,65) ___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
___ Line to Ground= 220 V
___ Neutral to Ground (< 3V)
Leakage test
Ground wire leakage to ground (100 uA max)
Chassis leakage to ground (exposed chassis)
(100 uA max)
Ground Continuity test
Ground pin to chassis
Ground
Neutral
Open
Normal Reversed
NA
NA
___uA
___uA
Line
Closed
Normal
Reserved
____uA
____uA
NA
NA
___ <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
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
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
___________________________________
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Electrocardiograph
Date
: __________________
Merk
: Nihon kohden
Period
: __________________
Serial No.
: _________________________
Room
: __________________
Visual Inspection :
L
Disconnect the cardiograph form AC power and inspect for the

Following :
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 :
Test Equipment Used

Remarks

: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Hypo/Hyperthermia Blanket Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
1. External cabinet and control panel in good condition.

______________
2. All warning labels properly affixed.
______________
3. Quick disconnect coupling (tight, straight, not leaking)

______________
4. Power Cord (no cuts or exposed wire) and
______________
plug no (bent or missing pin)

5.
Indicator lights (heat & cool , compressor, heaters, pump, power)
______________
6. Drain and clean reservoir
______________
7. Clean water filter
______________
8. Refill reservoir with distilled or sterile water

______________
9. Leakage current check ( all reading should be under 110 A for
______________
115/110 Volt AC and 500A for 230/240 Volt AC )
OFF normal polarity
_____________________
______________
OFF reverse polarity

ON normal polarity (heat)
ON reverse polarity (heat)
ON normal polarity (cool)
ON normal polarity (cool)
_____________________
_____________________
_____________________
_____________________
_____________________
10 . Condition of blanket, hoses, coupling (check for leaks)

______________
11. Refrigerant test :
12.
a. Clean condenser and fan
______________
b. Check sight glass
______________
Check temperature ( high / low and limit)
_______________________________
_______________________________
Test Equipment Used
: DPM 3 Temp test, multi meter
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
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
Chassis / Mounts/Fasteners
A. Pure Cut Levels
Controls/Switches
Selected
Fittings/Connector
10
375 25
Cables/Accessories
245 30
Indicators/Displays
160 30
Foot Switch
35 20
Isolation Switch
Low Frequency Output
REM Circuit
Delivered ( Watts)
Tolerance ( Watts)
B. Blends Levels
Selected
10
Delivered ( Watts)
Tolerance ( Watts)
250 25
10
Cooling Fan Test
140 40
11
Power On Switch and Circuit Breaker
95 20
25 15
C. Coag Levels
Selected
Delivered ( Watts)
Tolerance ( Watts)
10
125 15
75 10
45 10
10 5
Test Equipment Used
: RF 302 Electro surgical Analyzer
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
No
Equipment
: DEFIBRILATOR
Date
Merk
: ________________
Period :__________________________
Serial No.
: ___________________
Room :__________________________
Physical/Quantitative Test
Pass
Fail
:___________________________

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
Koreksi
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
11 Safety Checks
100 Joule
Deliver
12 Internal Cal. Test

Ket :
J dalam satuan JOULE
Test Equipment Used
: Defibrilator Analyzer QED 6
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Ventilator
Date
: _____________________
Merk
: _________________________
Period
: _____________________
Serial No.
: _________________________
Room
: _____________________
S/N
1
2
3
4
5
6
7
PPM CHECKLIST
Physical/Qualitative test
Chassis/Mounts/Fasteners
Controls/Switches
Fitting / Connectors
Cable / Accessories
Battery / Charger
Indicator / Displays
Alarms / Audible signals
S/N
Pass Fail 9
10
11
12
13
14
15
16
17
Calibration/ Verification checklist

Tidal Volume
Total Rate
I : E Ratio
Manual Breath
Alarm Silence
Expiration Time / Led
Apnea Time
Preset
Pressure (Peak, Mean,& Base)
Pass
Fail

1 Flow
a. Spontaneous Flow
B Main Flow
2 Respiratory Rate
3 Inspiratory Time
4 A/C Sigh
5 Nebulizer
6 Peep
7 Peak Inspiratory Pressure (PIP)
8 Leakage Test
18
19
20
21
22
23
24
25
26
27
Mode Selector
Trigger level
Low Pressure Alarm
High Pressure Alarm
External power Off/
Power Disconnect Alarm
Battery power
Low Battery Alarm
System Failure Alarm
Fl O2
Hour meter
Test Equipment Used
: RT 200 Calibration Analyzer
Remarks
: ___________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/
Biomedical. Eng
Equipment
: Timbangan Bayi
Date
: _____________________
Merk
: SECA
Period
: _____________________
Serial No.
: _________________________
Room
: _____________________
Massa Nominal (g)
Hasil Pembacaan(g)
Toleransi (g)
_______________
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)

1
Hasil Pembacaan(kg)
_______________
Toleransi (kg)
0.99-1,01
_______________
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
:-------------------------------------------------------------------------------
Test Equipment Used
: ___________________________________________________________
Remarks
: ___________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46
Biomedical. Eng

Equipment
: Transport Incubator
Date
: __________________
Merk
: _Datex Ohmeda_________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
2 Controls/Switches
3 Fiitings/Connectors
5 Battery/Charger
6 Indicator/Display
8 Air oxygen system
9 Temperature
10 Infant Chamber
11 Air Flow System
12 Tank Inspection
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: DOPPLER
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
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
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.46/1
Biomedical. Eng

Equipment
: Bed Pasien
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail

3 Fittings / Connectors
5 Indicator/Display
6 Hydraulic System
7 Brake System
8 Lubricating
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.46/1
Biomedical. Eng

Equipment
: NBP MONITOR
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail

5 Battery / Charger
Vdc
8 Manset
9 Self Test
10 Pump
11 Calibrasi
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: FETAL MONITOR / CTGDate
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Physical / Qualitative Test
Chassis / Mounts / Fasteners
Controls / Switches
Fiitings / Connectors
Cables / Accessories
Battery / Charger
Indicator / Display
Selft Test
Tranducer Test
Parameter Test
: __________________
Pass
Fail
Vdc
10 System Test
11
Printting Test
12 Beep
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Timbangan
Date
: _____________________
Merk
: Precise
Period
: _____________________
Serial No.
: _________________________
Room
: _____________________
Kinerja
No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Setting(gr)
1
2
5
10
20
50
100
200
500
1000
Terukur
Toleransi (gr)
0,99-1,01
1,98-2,02
4,95-5,05
9,9-10,1
19,8-20,2
49,5-50,5
99-101
198-202
495-505
990-1010
Test Equipment Used
: ___________________________________________________________
Remarks
: ___________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Incubator
Date
: _____________________
Merk
: Memmert
Period
: _____________________
Serial No.
: _________________________
Room
: _____________________
Terukur
Toleransi
36,63-37,37
37,62-38,38
59,4-60,6
Kinerja
No
1.
2.
3.
Setting Suhu pada alat( C)

37
38
60
Visual inspection
Main unit
Accessories
Cleaning
Function
Pass
Fail
Test Equipment Used
: ___________________________________________________________
Remarks
: ___________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist Peruangan

Equipment
: Tensimeter
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
No
1
ITEM
Pengecekan Fisik
KEADAAN NORMAL
Kondisi baik dan bersih,
tidak ada lumut/jamur, dan
segala kelengkapan nya
ada semua (manset, balon
pompa, air raksa, tubing
KONDISI
KETERANGAN
spiral)
Pengecekan Manset
Pengecekan tabung,
glass dan air raksa
Pengecekan Balon
Pompa
Pengecekan tekanan
Kondisi karet manset baik

tidak ada kebocoran
Tabung dan glass
manometer baik sehingga
air raksa tidak ada yang
tumpah/ tetap menunjuk di
angka 0 )
Balon pompa tidak ada
kebocoran, elastisitasnya
baik, pentil angin dan valvenya baik
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
Water Supply (cold and Hot)
Float Switch
Break Tanks
Pump
Timer
Heater
Probes, Sensor, Thermostats
Start Button
Key Switch
Pass
Fail
10 Door Micro switch

11
Door Mechanism/seal
12 Indicator Lights
13 Foot Bellows and Air Switch
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
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/of
______________
Test Equipment Used
: Tool set
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Phototherapy Lamp
Date
Merk
: Air-shields
Period : __________________
Serial No.
: _________________________
Room : __________________
NO
Chassis/mounts/Fasteners
Controls/Switches
Fittings/Connectors
Cables/Accessories
Timer
Indicator/Display
Cooling Fan
: __________________
Pass
Fail
Bulb
9
Light output Check
uw/cm2
10 Cleaning
Test Equipment Used
: Phototherapy Radiometer
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Eagle Ten Sterilizer
Date
Merk
: Amsco
Period : __________________
Serial No.
: _________________________
Room : __________________
NO

Preparation
Door Assembly
Selenoid Valve
Over temperature Controller
Air Vent (Steam)
Gauge
Chamber & Water Reservoir
: __________________
Pass
Fail
Control Components
Final Test
Test Equipment Used
: DPM III, Fluke Multimeter
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Baby Incubator
Date
Merk
: Air-Shields
Period : _____________
Serial No.
: ________________
Room : _____________
S/N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
PPM CHECKLIST
Operational Checkout Procedure
Power Failure
AC Power Cord
VHA Stand
Hood Hinge and Latch operation
Access Panel Detent and Noise Level
Air Curtain Cover
Main Deck
Iris Entry Port
Access Panel Latches
Access Door Latch
Mattress Elevators
Mattress Tray Operation
Air Intake Micro filter
Oxygen Input Valve Filter
Air/Oxygen System
: _____________
Pass Fail S/N Operational Checkout - Controller

1 Air Control Mode Of Operation
2 Air Set Temperature Alarm
3 Air Auxiliary Probe
4 Baby Control Mode Of Operation
5 Baby Set Temperature Alarm
6 Baby Temp Probe Fail Alarm
7 Air Flow Alarm
8 Max Air Temperature
Pass
Fail
Test Equipment Used
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
1
2
3
4
5
6
7
8
9
10
11
12
13
Pass
Fail
Description
Pass
Fail
Description
Table Console
Probe Holders
Control Panel
Brake system
Probe
Monitor
Cooling / Fans
Keyboard Harness
Power Cord
Voltage Stabilizer
Cover
Peripheral Input / output
Printer
2. System Diagnostics Checklist

No
Item
1
2
3
4
5
: __________________
Error Check
Keyboard Function Check
Color Monitor System Check
Configuration Color Printer
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
No
Item
1
2
3
4
5
6
7
8
9
10
11
12
13
Fail
Description
Pass
Fail
Description
Table Console
Probe Holders
Control Panel
Brake system
Probe
Monitor
Cooling / Fans
Keyboard & Track Ball
Power Cord
Voltage Stabilizer
Cover
Peripheral Input / output
Printer
2. System Diagnostics Checklist

No
Item
1
2
3
4
5
Pass
Error Check
Keyboard Function Check
Color Monitor System Check
Configuration Color Printer
Calibration
Test Equipment Used
: ______________________________________________
Remarks
: ______________________________________________
Performed By:__________________
Verified By: ___________________

BM.0308.46/1
Biomedical. Eng

Equipment
: Surgical Table
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Preparation
Hydraulic System
Casters and Floor Locks
Controls
Electrical Checks
Table Rigidity
Final Test
Pass
Fail
Test Equipment Used
: Fluke Multimeter
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.46/1
Biomedical. Eng

Equipment
: Obgyn Chair
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Preparation
Hydraulic System
Casters and Floor Locks
Controls
Electrical Checks
Chair Rigidity
Final Test
Pass
Fail
Test Equipment Used
: Fluke Multimeter
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: ENT Unit
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Fittings / Connectors
Indicator Display
Warm Water System
Light System
Suction System
Mirror Warming
Pass
Fail
10 Compressed Air System

11
Stroboscope
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: SPIROMETER
Date
: __________________
Merk
: ________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Indicator Display
AC-DC Adaptor
Transducer
Printer
Pass
Fail
Test Equipment Used
: Fluke Multimeter
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Dental Unit
Date
: __________________
Merk
Periode
: __________________
Serial No.
: ________________________
Room
: __________________
NO
Physical/Qualitative Test
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
Pass
Fail
Description
Test Equipment Used : DPM III, Fluke Multimeter

Remarks : _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Performed by :_________________
Verified by :_________________
BM.0308.46/1
Biomedical. Eng

Equipment
: STERILIZER
Date
: _________________
Merk
: Iwaki
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO

Preparation
Door Assembly
Solenoid Valve
Over temperature Controller
Air Vent (Steam)
Gauge
Chamber & Water Reservoir
Pass
Fail
Control Components
Final Test
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Cauter
Date
: __________________
Merk
: Martin________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Indicator Display
Electrode
Foot Switch
Surgical Output
Test Equipment Used
Pass
: ESU Analyzer, Fluke Multimeter
Fail
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Infusion Pump
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
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
Pass
Fail
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Syringe Pump
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
1 Self Diagnosis
2 Dial
3 Clear ml
4 Buzzer Volume
5 Body weight mode
6 Syringe size detection
7 Nearly empty alarm
8 Occlusion
9 Flow rate accuracy
10 Battery
Test Equipment Used
: ________________________________________________________
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
Pump Lubrication
Pump Cylinder
Solenoid Valve
Fan
Control Circuit
Collection Bottle and Cap Assembly
Manometer Tube Sterilization
Casing
Brake System
Pass
Fail
Description
10
11
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: BREAST PUMP
Date
: __________________
Merk
: MEDAP
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pump Lubrication
Pump Cylinder
Solenoid Valve
Pressure Regulator
Control Circuit
Casing
Brake System
Pass
Fail
Description
10
11
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : ______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Liquid Oxygen Central
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Indicator Display
Liquid Tank
Safety Valve
Regulator System
Pass
Fail
Description
9 Alarm System
10 Pressure Meter
11
Reserve Cyllinder
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Nitrous Oxide Central
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
Description

3 Fittings / Connectors
5 Indicator Display
6 Cyllinder Connector
7 Safety Valve
8 Regulator System
9 Alarm System
10 Pressure Meter
11 Reserve Cyllinder
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Nitrogen Central
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Indicator Display
Cyllinder Connector
Safety Valve
Regulator System
Pass
Fail
Description
9 Alarm System
10 Pressure Meter
11
Reserve Cyllinder
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Medical Air Equipment
Date
: __________________
Merk
: ATLAS COPCO
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Indicator Display
Reverse Cylinder
Safety Valve
Regulator System
Alarm System
Pass
Fail
Description
10 Pressure Meter
11 Motor Compresstion
12 Oil Motor Compresstion
13 Filter Air
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Vaccum Equipment
Merk
Serial No.
NO
Date
: __________________
: Ohmeda
Period
: __________________
: _________________________
Room
: __________________
Controls / Switches
Indicator Display
Vaccum Machine
Safety Valve
Regulator System
Alarm System
Pass
Fail
Description
10 Pressure Meter
11 Oil Mechine
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Anaesthetic Gas Scavenging
Date
: __________________
System
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Controls / Switches
Indicator Display
Vaccum Machine
Alarm System
Pass
Fail
Description
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Mixer
Date
Merk
: __________________
Period
: _______________
Serial No.
: _________________________
Room
: Laboratorium
NO
Motor
Controls / Switches
Line Indicator
Pass
Fail
Keterangan
Function test
Mixer Selector mode: FULL
TOUCH
Speed control
: LOW
MEDIUM
HIGH
Test Equipment Used
: Multi Meter, tool Set
Remarks
: _____________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: TONOMETER
Date
Merk
Period
Serial No.
: _________________________
Room
: Eye Center
NO
Pass
Fail
Description
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
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Ultrasonic Biometer
Date
Merk
Period
: __I_______________
Serial No.
: ______________________
Room
: Eye Centre
NO
Pass
Fail
Description
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
Test Equipment Used
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.64/1
Biomedical. Eng

Equipment
: Injector Contras
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Motor
Controls / Switches
Line Indicator
Function test
Pass
Fail
Description
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
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.64/1
Biomedical. Eng

Equipment
: Retinal Camera
Date
:__________________
Merk
Period
:I
Serial No.
: _________________________
NO
Pass
Room
Fail
: Eye Center
Description
2 Controls/Switches
4 Indicator/Display
5 Camera
6 CPU
7 Printer
8
9
10
11
12
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: OPERATING LAMP
Date
:__________________
Merk
: _________________________
Periode
:__________________
Serial No.
: _________________________
Room
:__________________
NO
Power / Adaptor Voltage
Cables /Accessories
Dimmer Regulator System
Brake Rotary System
Focus System
Cleaning
Pass
Fail
Description
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: MICROSCOPE
Date
:__________________
Merk/Type
: _________________________
Periode
:__________________
Serial No.
: _________________________
Room
:__________________
NO
Power / Line Indicator
Cables /Accessories
Dimmer System
Bulb Lamp
Focus System
LENS Cleaning
Pass
8 Balancing
Test Equipment Used
: Alcohol ,tool set
Fail
Description
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
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
1 Supported Table Top
a. With base cover raised
b. When base cover is not Raised
2 Floor Locks
a. Floor locks improperly adjusted
b.Binding of pedal linkage
c.Insufficient clearance between pedal
And floor
d.Pedal Sticks in Up Position
e.Pedal not Return To Maximum Up
Position
3 Pump Pedal Adjustment
4 Hydraulic System
a.Oil Level
b.Strainer
S/N
Pass
8 Drive Crank Clutch Adjustment
9 Side Tilt Adjustment
10 Selector Handle Locating AdjustmeMent
11 Friction Device on Lift Cylinder
Adjustment
12 Kidney Elevator Handle
13 Lateral Movement Stop Pin Adjus
Ment
14 Tredelenburg Hand Crank
15 Lateral Tilt Mechanism
16 ShiftLever Modification
17 Lubrication
Fail
c.Hydraulic Leakage
5 Table Elevation
6 Table Top Positioning
7 Lift Carriage Adjustment
Test Equipment Used
: Multimeter, Tool Set
Remarks
: ___________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: WARMING CABINET
Date
:__________________
Merk/Type
: AMSCO
Periode
:__________________
Serial No.
: _________________________
Room
: ___________________
NO
Power / Line Indicator
Cables /Accessories
Heating Filament
Fan
Door Sensor
Display
Clean Cabinet
Heat Sensor
Pass
Fail
Description
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Oxygen Transfer
Date
Merk
Merk
Serial No.
: _________________________
Room
: __________________
NO
1

Pass
Fail
Description
Fitting/connector
Regulator
Pressure meter
Pipe
Test Equipment Used
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Scrub Station
Date
: ________________________
Merk
: Amsco
Period
: ________________________
Serial No.
Room
: ________________________
NO
2 Goose Neck/Rose Spray
Pass
Fail
Description
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:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Campimeter
Date
: ________________________
Merk
: Humprey
Period
: ________________________
Serial No.
Room
: ________________________
No.
Bagian Alat
Pemeriksaan
Fisik
Pemeriksaan Fungsi
Keterangan
Baik
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Tidak Baik
Baik
Tidak Baik
Badan /Permukaan
Kabel/Konektor
Saklar/Indicator
Printer,key board,mouse
Monitor
Lampu
Filter Udara
System self Cek
System LOG
Tegangan AC 220V
Test Equipment Used

Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Tourniquet System
Date
: _________________
Merk
: zimmer
Period
: _________________
Serial No.
Room
: __________________
NO
Pass
Fail
Description
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
Test Equipment Used
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
:Cam Vision Stimulator
Date
: ________________________
Merk
Period
: ________________________
Serial No.
Room
: ________________________
No.
Bagian Alat
Pemeriksaan
Baik
1.
2.
3.
4.
5.
Fisik
Tidak Baik
Pemeriksaan Fungsi
Baik
Keterangan
Tidak Baik
Badan /Permukaan
Kabel/Konektor
Saklar/Indicator
SLIDE Simulator
Motor
Test Equipment Used
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Equipment
: Cromoganic Kinetic SYS.Date
: ________________________
Merk
: Helena Laboratories
Period
: ________________________
Serial No.
Room
: Laboratorium
No.
Bagian Alat
Pemeriksaan
Baik
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Fisik
Tidak Baik
Pemeriksaan Fungsi
Baik
Keterangan
Tidak Baik
Badan /Permukaan
Kabel/Konektor
Saklar/Indicator
Monitor
Printer
Unit
Key Board
Lampu
Filter Udara
Pipet
Test Equipment Used

Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Oxygen Flow meter
Date
: ________________________
Merk
: Ohmeda/CIG
Period
: ________________________
Serial No.
Room
: ________________________
No.
Bagian Alat
Pemeriksaan
Baik
1.
2.
3.
4.
Bola penunjuk
Regulator
Botol Humidifier
Volume output
Fisik
Tidak Baik
Pengukuran
1 Lpm
2 Lpm
3 Lpm
4 Lpm
5 Lpm
10 Lpm
15 Lpm
Pemeriksaan Fungsi
Baik
Keterangan
Tidak Baik
Terukur
Toleransi
0,95-1,05
1,9-2,1
2,85-3.15
3,8-4,2
4,75-5,25
9,5-10,5
14,25-15,75
Test Equipment Used

: Multi Meter, RT-200 Cal Analyzer,tool Set
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Suction Regulator
Date
: ________________________
Merk
: Ohmeda
Period
: ________________________
Serial No.
Room
: ________________________
No.
Bagian Alat
Pemeriksaan
Baik
1.
2.
3.
4.
Saklar On/off
Regulator
Jarum /meter penunjuk
Suction output
Fisik
Tidak Baik
Pengukuran
- 100 mmHg
- 200 mmHg
- 300 mmHg
- 400 mmHg
- 500 mmHg
- 600 mmHg
- 700 mmHg
Pemeriksaan Fungsi
Baik
Keterangan
Tidak Baik
Terukur
Toleransi
95-105
190-210
285-315
380-420
475-525
570-630
665-735
Test Equipment Used

: Multi Meter, DPM III,tool Set
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Suction Regulator
Date
: ________________________
Merk
: Ohmeda/ Thoracic
Period
: ________________________
Serial No.
Room
: ________________________
No.
Bagian Alat
Pemeriksaan
Baik
1.
2.
3.
4.
Saklar On/off
Regulator
Suction output
Fisik
Tidak Baik
Pengukuran
5 cmH2O
15 cmH2O
25 cmH2O
40 cmH2O
50 cmH2O
60 cmH2O
Full Vac
Pemeriksaan Fungsi
Baik
Keterangan
Tidak Baik
Terukur
Test Equipment Used

: Multi Meter, RT 200,tool Set
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Suction Regulator
Date
: ________________________
Merk
: Ohmeda
Period
: ________________________
Serial No.
Room
: ________________________
No.
Bagian Alat
Pemeriksaan
Baik
1.
2.
3.
4.
Saklar On/off
Regulator
Suction output
Fisik
Tidak Baik
Pengukuran
- 20 mmHg
- 60 mmHg
- 80 mmHg
- 120 mmHg
- 160 mmHg
- 200 mmHg
Full Vac
Pemeriksaan Fungsi
Baik
Keterangan
Tidak Baik
Terukur
Toleransi
19-21
57-63
76-84
114-126
152-168
190-210
Test Equipment Used

: Multi Meter, DPM III,tool Set
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Autorefraktometer
Date
: ________________
Merk
Period
: _________________
Serial No.
Room
: __________________
NO
Chassis / Mounts
Control / Switch
Fitting / Connector
Cable / Accessories
Indicator / Display
Printer
Test Equipment Used
Pass
Fail
Description
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : ____________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Head Lamp
Date
: _________________
Merk
Period
: _________________
Serial No.
Room
: __________________
NO
Chassis / Mounts
Control / Switch
Fitting / Connector
Cable / Accessories
Indicator / Display
Lamp
Test Equipment Used
Pass
Fail
Description
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : ____________________
BM.0308.46/1
Biomedical. Eng

Equipment
: PHOROPTOR
Date
: _________________
Merk
Period
: _________________
Serial No.
Room
: _________________
NO
Chassis / Mounts
Control / Switch
Fitting / Connector
Cable / Accessories
Indicator / Display
Lamp
Test Equipment Used
Pass
Fail
Description
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : ____________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Rehab Chair
Date
:__________________
Merk
: Sinwanai
Period
Serial No.
: _________________________
Room
NO
Pass
Fail
Description
2 Controls/Switches
4 Cables/accessories
5 Indicator/Display
6 Timer
7 Over loud
8 Speed adjusted
9 Motor
10
11
12
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Traction Machine
Date
:__________________
Merk
: Triton
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
Pass
Fail
Description
2 Controls/Switches
5 Indicator/Display
6 Timer
7 Belt/Suspension
8 Patient Switch Activated
9 Static /Intermittent
10 Traction Progress
11
12
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Rigidometer
Date
:__________________
Merk
: Uroan
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
2 Controls/Switches
5 Indicator/Display
6 Sensor
7 Electric Charge
8 Battery
9 Computer Unit
10
11
12
Pass
Fail
Description
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Ultrasound Therapy
Date
:__________________
Merk
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
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
Pass
Fail
Description
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: EEG
Date
:__________________
Merk
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
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
Pass
Fail
Description
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Tympanometer
Date
:__________________
Merk
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
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
Pass
Fail
Description
11
12
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Nebulizer
Date
:__________________
Merk
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
2 Power line
4 Ultrasonic Electrode
5 Timer
6 Sensor Water Level
7 Air Filter
8 Fan
9 Cleaning
Pass
Fail
Description
10
11
12
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.64/1
Biomedical. Eng

Equipment
: FILM SCREEN
Date
:__________________
Merk
: _________________________
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Bulb
7 Film Roller
Pass
Fail
Description
Forward & Reverse System
9 Cover
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.64/1
Biomedical. Eng

Equipment
: Washer
Date
:__________________
Merk
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
Pass
Fail
Description
6 Water Supply
7 Air Supply
8 Drain System
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Light Source
Date
:__________________
Merk
: _________________________
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
Pass
Fail
Description
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
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Steam Boiler
Date
:__________________
Merk
: AMSCO
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
Cable/Accessories
Pressure Steam
Connecting Pipe
Cold Water Inlet
Hot Water Inlet
Glass Level
Water Pump
Water Sensor Level
Heater
Pass
Fail
Description
10 Check Valve
11 Drain
12 Pressure Meter
13 Safety Valve
Test Equipment Used
: Fluke Multimeter, Tool Set
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: OPTOTIF PROYEKTOR
Date
: _________________
Merk
Period
: _________________
Serial No.
NO
Room
Chassis / Mounts
Control / Switch
Fitting / Connector
Cable / Accessories
Indicator / Display
Lamp
Test Equipment Used
Pass
: _________________
Fail
Description
Remarks:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : ____________________
BM.0308.46/1
Biomedical. Eng
Equipment
: Auto Fluid Balance Monitor
Date
:__________________
Merk
: Aquarius
Period
:__________________
Serial No.
: _________________________
Room
:_________________
NO
Pass
Fail
Description
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
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Patient Warming System
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Cast Cutter
Date
:__________________
Merk
: Stryker
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Motor
7 Vacum

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Paracare
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Heater/Temperatur

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Intelect Advanced
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indikator/Display
6 Pad Elektrode
7 Intensity

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Blood Warmer
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Heater
7 Line Of Tubing Set

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Laser Argon
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Colling System
7 Laser Output

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Laser YAG
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Laser Output

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Static Bike
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Tilt Table Lifeline
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Motor/Hydraulic System
7 Lubricating

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: CPM
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Drying Cabinet
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Fan
7 Heater
8 Cleaning

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: ID Camera
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lamp
7 Motor
8 Cleaning
Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Water Filter Amway
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lamp UV
7 Filter
8 Cleaning
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Cassette Autoclave
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Control/Switches
Fitting/Connector
Cable/Accessories
Indicator/Display
Cleaning
Air Filter
Cassette
Reservoir
Wash Bottle
Pass
Fail
Description
10 Lubricating/Changing Cassette seal

11 Temperature
12 Aluminium Antena & Holder
Test equipment used :.._____________________
Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Equipment
: EMG
Date
:__________________
Merk
Period
:__________________
Serial No.
: _________________________
Room
:__________________
NO
Pass
Fail
Description
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
Test Equipment Used
Remarks
: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Bilirubinometer
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Power/Line Indikator
4 Bulb Lamp
5 Cleaning

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Blood Bank
Date
:__________________
Merk
: Sanyo
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Controls/Switches
3 Fitting/Connector
4 Indikator/Display
5 Cable/Accessories
6 Temperature
7 Freezer

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Centrifuge
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Ultrasonic Cleaner
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
3 Power/Adaptor
4 Rack system
5 Indikator
6 Timer
7 Cleaning
8
9
10
11

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Oxicom
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
4 Control/Switches
5 Indikator display
6 Sensor
7
8
9
10
11

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Unit Endoscopy
Date
:__________________
Merk
: OLYMPUS
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Polymerization Light
Date
:__________________
( Light Curing )
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
1 Chassis / Mount / Fasteners

2 Control / Switches
3 Fitting / Connector
5 Cable / Accessories
6 Hand Piece
7 Lamp

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Infant Warmer
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description

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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Short Wave Diathermy
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Microwave Diathermy
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Electric Stimulator
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description

6 Brake system
7 Vacuum System
8 Pad electrode
9 Water reservoir
10 Intensity
11
12
13
Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Infra Red Lamp
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO

6 Timer
7 Lamp
8
9
10
11
12
13
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Cusa Unit
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO

6 Pump Irrigation
7 Suction
8
9
Pass
Fail
Description
10
11
12
13

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Bor Tulang
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO

2 Power Line Indicator
4 Accessories
5 Gas Supply
6 Motor System
7 Drill Rotating
Pass
Fail
Description
8
9
10
11
12
13

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Electronic Laparofator
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO

4 Accessories
5 Gas Supply
Pass
Fail
Description
6
7
8
9
10
11
12
13

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Nerve Detector
Date
:__________________
Merk
: ______________________
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO

Pass
Fail
Description
4 Accessories
5 Battery
6
7
8
9
10
11
12
13

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Suction Pump Unit
Date
: __________________
Merk
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pump Lubrication
Pump Cylinder
Valve
Regulator
Control Circuit
Casing
Brake System
Pass
Fail
Description
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: SPIROMETRI
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail

5 Battery / Charger
8 Tranduser
9 Cabel + Conector Tranduser
10 Beep
11 Calibrasi
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM 0308.4
Biomedical. Eng
Equipment
: Cell Dyn 3500
Date
:__________________
Merk
: Abbott
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
4 Control/Switches
5 Indikator display
6 Tubings
7 Valve

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Axsym System
Date
:__________________
Merk
: Abbott
Period
:__________________
Serial No.
: ______________________
Room
:__________________
NO
Pass
Fail
Description
4 Control/Switches
5 Indicator/ display
6 Monitor
7 Printer

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Bactec
Date
:__________________
Merk
: Becton Dickinson
Period
:__________________
Serial No.
: ______________________
Room
:__________________
NO
Pass
Fail
Description
4 Control/Switches
5 Indikator display
6 Heater

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: ENTONOX
Date
:__________________
Merk
: Jono Mark II
Period
:__________________
Serial No.
: ______________________
Room
:__________________
NO
Pass
Fail
Description
3 Oxygen Accessories
4 Nitrous Oxide Accessories
5 Mixer (%)
6 Test Lung

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Heart Lung Machine
Date
: __________________
Merk
: Stockert S3
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
2 Controls/Switches
3 Fiitings/Connectors
5 Battery/Charger
6 Indicator/Display
8 Pump
9 Pressure Meter
10 Power Suplay Voltage (5 V, 12 V, 15 V dan 24 V)
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Anaesthetic Machine
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
2 Controls/Switches
5 Battery/Charger
6 Indicator/Display
7 Gas Supply
8 Bellows Rubber
9 Pressure Meter
10 Gas Monitoring System
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: IABP
Date
:__________________
Merk
: Datascope
Period
:__________________
Serial No.
: ______________________
Room
:__________________
NO
Pass
Fail
Description
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
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Oximeter
Date
: __________________
Merk
: _________________________
Period
: __________________
Serial No.
: _________________________
Room
: __________________
NO
Pass
Fail
2 Controls/Switches
5 Battery/Charger
6 Indicator/Display
7 SPO2 Sensor
Test Equipment Used
: ________________________________________________________
Remarks
: ________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: CPAP
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Doctor Operating Chair
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
1 Preparation
2 Hydraulic System
3 Caster and Floor Locks
4 Controls
5 Electrical Checks
6 Chair Rigidity
7 Final Test
8
9
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Slit Lamp
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lamp
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Dental X-Ray
Date
:__________________
Merk
Period
:__________________
Serial No.
: _______________________
Room
:__________________
NO
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lubrication Rel Up/Down
7 Mechanical Checks
8 Cleaning
Pass
Fail
Description
9 Functional Checks
Setting Pada Alat

KVp
Second
Terukur
KVp
Second
Koreksi
KVp
Second

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Uroflow
Merk
Date
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
Pass
Fail
Description
5 Indicator/Display
6 Volume Transducer
7 Printer
8 Measurement cup

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: AUDIOMETER
Date
:__________________
Merk
Period
:__________________
Serial No.
: _______________________
Room
:__________________
PPM Check List
PPM Check List
S/N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Physical/qualitative test
Power on/off
Present/Interrupt Switch (2)
Left/Right Earphone Selector
Stimulus on (interrupt)
Stimulus off (Present)
Automatic Pulsing
Frequenchy Modulation (FM)
Test Signal
+ 10 dB Switch
Tone Stimulus Select
Tape/Microphone Select
Speaker Select
+ 2.5 Select
Talk Forward
Frequency Select Control Doal
Intensity Control Dial
Masking Level Control
Test Microphone Level Control
Pass
Fail
S/N
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Pass
LED Read Out of Frequency Selected
LED Read Out Of Intensity Selected
LED Indicator (subject Respond)
LED Indicator (Stimulus Present)
LED Indicator of Active Test
Earphone or Masking For Bone
LED indicator Stimulus On/Off
LED Idicator of Auto Pulsign
LED Indicator for FM
LED indicator for masking level
intensity
LED indicator of +10 dB
LED Indicator Earphone/Bone
LED Indicator of +2.5 dB
LED Indicator Speaker Selectionu
LEDIndicator of Tone Stimulus
LED Indicator of Tape or
Microphone Stimulus Selected
Speech Level VU meter

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Fail
Biomedical. Eng
LAPORAN PEMERIKSAAN ALAT BARU

Equipment
: Mesin Hemodialisa
Merk
Date
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
1 Working Hours
2 Flow 300 (Dialisis)
5 Blood Leak
6 Dimnes
7 Blood Pump Rate
8 Check Temperature

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Resuscitator
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Fibrintimer
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Rotator
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Water Bath
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6 Temperature
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Thermasealerr
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Retraction
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Histocantre
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Croytom
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Chiller
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Lemari Asam
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
:Thermasealler
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Pass
Fail
Description

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
:Cryotome
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
Pass
Fail
Description
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
: Clinitex
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
Pass
Fail
Description
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
:Radrometer
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
2 Control/ Switches
Pass
Fail
Description
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1
Biomedical. Eng

Equipment
:Architect
Date
:__________________
Merk
Period
:__________________
Serial No.
: ______________________
Room
:_________________
NO
Pass
Fail
Description
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9

Remarks
: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________
Verified by : _______________________
BM.0308.46/1

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Biomedical.

Preventive Maintenance Checklist

: Mac. Lab. Monitoring

Computer module housing

Line / Power plug

Line / Power cord

Display fuse holder

System cables at rear of Display &

Rack & Parameter Module connectors

Patient safety checks

Indicators on / off and screen

LEDs on the parameter Module

Visual and audible Alarm

Test Equipment Used

: ECG Stimulator BIOTEK, Fluke multi meter

Preventive Maintenance Checklist

Film Guide Assembly

Main Drive Assembly

Water Flow to the Processor

Test Equipment Used

Preventive Maintenance Checklist

Disconnect the cardiograph form AC power and inspect for the

Loss or missing hardware

Frayed or damage wiring

Evidence of liquid spill

Printer drive gear wear

Printer roller wear

Wear or damage to power cord and

Corroded or damage electrodes

Damage lead wires or patient module cable ____________________________

Connect the cardiograph to AC power and turn on the AC switch.

each test passes with no errors.

Electrocardiograph Simulation : Record an ECG wave using an ECG simulator.

Test Equipment Used

: ECG Stimulator BIOTEK, Fluke multi meter

Preventive Maintenance Checklist

Power Supplies/Diagnostic test

+16,5 V dc ( 1,65) ___Volts

Electrical safety test

AC line voltage test

___ <0.1 ohm

Test Equipment Used

: Tacho meter , Electric Safety Analyzer, ECG Stimulator

LAPORAN PEMERIKSAAN ALAT BARU

Computer module housing

Line / Power plug

Line / Power cord

Display fuse holder

System cables at rear of Display &

Rack & Parameter Module connectors

Labeling and accessories

Patient safety checks

Indicators on / off and screen

LEDs on the parameter Modules

Visual and audible Alarm

Test Equipment Used

: ECG Stimulator BIOTEK, Fluke multi meter

Preventive Maintenance Checklist

Disconnect the cardiograph form AC power and inspect for the

Loss or missing hardware

Frayed or damage wiring

Evidence of liquid spill

Printer drive gear wear