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Facility: Dept:
WO No.: Date: Inspector:
Mfr: Model: SN:
CTRL No: Loc: IPM Time:
SPECIAL PRECAUTIONS
TEST APPARATUS
Control/Serial No.
Electrical safety analyzer
Pressure meter (50 psi)
Infusion pump tester - optional
50 mL graduated cylinder (1 mL graduations)
Electronic balance (200 g range, 0.1 mg resolution)
5 mL pipette (0.1 mL graduations)
Stopwatch or watch that displays seconds
QUALITATIVE TASKS
Pass Fail
Chassis/Housing
Mount
AC Plug
Line Cord
Strain Reliefs
Fittings/Connectors
Controls/Switches
Battery
Indicators/Displays
Self-Test
Time/Date Settings
Network/Wireless Interfaces
Alarms
Audible Signals
Open Door/Misloaded Infusion Set
Free-flow Prevention Mechanism(s)
Occlusion
Labeling
QUANTITATIVE TASKS
Criteria Set/Indicated Measured Pass Fail
Grounding Resistance 0.5
Flow Accuracy 5%
Maximum Pressure 1 psi of
acceptance test
pressure
Air-in-Line Detection 50 to 100 L
PREVENTIVE MAINTENANCE
Done
Replace
NOTES