Appendix H Sample Acceptance Test Log Sheet

Only when this form has been satisfactorily completed should the Registration Box be filled in by the Head
of Medical Equipment Maintenance.

REGISTRATION BOX

ALLOCATED INVENTORY NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EQUIPMENT TYPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DESTINATION LOCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACCEPTANCE DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WARRANTY EXPIRY DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MAINTENANCE CONTRACT WITH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HEALTH FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NAME OF EQUIPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TYPE/MODEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ORDER NUMBER . . . . . . . . . . . . . . . . . . . . . . SERIAL NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . .

COST. . . . . . . . . . . . . . . . . . . . . . . . . DATE RECEIVED . . . . . . . . . . . . . . . . . . . . . . . . . .

MANUFACTURER . . . . . . . . . . . . . . . . . . . . . SUPPLIER/AGENT . . . . . . . . . . . . . . . . . . . . . . . . . .

ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.................................... ...........................................

PHONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PHONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DETAILS OF ALL ACCESSORIES, CONSUMABLES, SPARE PARTS AND MANUALS RECEIVED ARE
LISTED ON THE FOLLOWING PAGE OF THIS FORM.
Page 2

ACCEPTANCE CHECKS
1. DELIVERY
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . .
. . …………..
Yes/done No/not Corrected if
Points to considered done applicable
a) Representative of supplier present?
b) Correct number of boxes received?
c) After unloading, visible damage to the boxes?
d) If damaged, has this been stated on the delivery
note and senior management informed?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
2. UNPACKING (refer to invoices and shipping documents)
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . .
...
Points to considered Yes/done No/not done Corrected if
applicable
a) Visible damage to the equipment?
b) Equipment complete as ordered?
c) User/operator manual as ordered?
d) Service/technical manual as ordered?
e) Accessories as ordered?
f) Consumables as ordered?
g) Spare parts as ordered?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
Page 3

3. ASSEMBLY (refer to manuals)

Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . ……………

Points to considered Yes/done No/not done Corrected if

applicable
a) Are all parts available?
b) Do they fit together?
c) Mains lead with plug included?
d) Do all the accessories fit?
e) Are markings and labels OK?
f) Any damage?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
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4. INSTALLATION (refer to manuals)

Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . . ……...

Points to considered Yes/done No/not done Corrected if applicable

a) Was the work carried out satisfactorily?
b) Were technical staff present as learners?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Page 4

5. COMMISSIONING/TESTING
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . . …………

Points to considered Yes/done No/not done Corrected if

applicable

a) Were electrical, mechanical, gas, radiation safety tests

and performance checks carried out in accordance with
the test sheets on pages 7 to 9 of this form?

b) Was the work carried out satisfactorily?

c) Were technical staff present as learners?

d) Were operators present as learners?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................

6. ACCEPTANCE – to be certified by the Head of Equipment Maintenance only

Points to considered Yes/done No/not done Corrected if
applicable

a) Is the equipment accepted?

b) If rejected, have the shortcomings been summarized
on page 10 of this form
c) If so, has a report gone to senior management
and formal complaints procedures started?
d) Should payment be withheld pending corrections?
e) Is payment approved?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Page 5
7. TRAINING
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .

Yes/done No/not Corrected if

done applicable

a) Were the expected training courses given? ...... ...... ......

b) Were the training courses satisfactory? ...... ...... ......

c) Were suitable operators present? ...... ...... ......

d) Were suitable technical staff present? ...... ...... ......

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................

8. REGISTRATION – to be undertaken by the Head of Medical Equipment Maintenance

Points to considered Yes/done No/not done Corrected if
applicable

a) If accepted, has an inventory number been allocated?

b) Has the Registration Box on Page 1 of this form been filled in?

c) Has the Stores Controller been provided with the location

for the equipment and all necessary data, so that the
Stores Receiving Procedure can be followed and a
Goods Received Note completed?

d) Have the accessories, consumables, spare parts, and manuals

all been issued to the correct holding authorities?

NAME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NOW PLACE THIS FORM AS THE FIRST RECORD IN THE EQUIPMENT FILE/SERVICE HISTORY
Page 6

Describe and quantify all items received, and complete a Register of New Stocks form:
ACCESSORIES RECEIVED
1. ……………………………………….. 5. ………………………………………..
2. ……………………………………….. 6. ………………………………………..
3. ……………………………………….. 7. ………………………………………..
4. ……………………………………….. 8. ………………………………………..

CONSUMABLES RECEIVED
1. ……………………………………….. 5. ………………………………………..
2. ……………………………………….. 6. ………………………………………..
3. ……………………………………….. 7. ………………………………………..
4. ……………………………………….. 8. ………………………………………..

SPARE PARTS RECEIVED

1. ……………………………………….. 5. ………………………………………..
2. ……………………………………….. 6. ………………………………………..
3. ……………………………………….. 7. ………………………………………..
4. ……………………………………….. 8. ………………………………………..

MANUALS RECEIVED
1. ………………………………………..
2. ………………………………………..
3. ………………………………………..
4. ……………………………………….
 Page 7
9. COMMISSIONING/TESTING PROCEDURES (see manuals and relevant technical
standards)

i. ELECTRICAL INTEGRITY TESTS

Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .
Classification (applies to medical equipment only)

Classification Fill as applicable

a) Class I - II - III?
b) Type B - BF - CF?
c) Type AP - APG?

Yes/done No/not done Corrected if

Mains Connection applicable
a) Are cables and plugs intact?
b) Is cable color code correctly connected?
c) Are connectors intact?
d) Are the fuses correct?
e) Is equipment protection correct?
f) Is voltage setting correct?
g) Is there an earth terminal?

Yes/done No/not done Corrected if

Electrical Measurements with Safety Tester applicable
a) Is protective earth continuity correct?
b) Is insulation resistance correct?
c) Are the leakage currents correct?
d) Is the voltage measurement correct?

omments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Page 8
ii. MECHANICAL INTEGRITY TESTS
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .

Mechanical Integrity Tests Yes/done No/not done Corrected if applicable

a) Are knobs and switches intact?
b) Do the wheels/castors move?
c) Are the handles intact?
d) Are the mechanical movements okay?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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iii. GAS INTEGRITY TESTS

Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .

Gas Integrity Tests Yes/done No/not done Corrected if applicable

a) Are the cylinders full?
b) Are appropriate gauges available?
c) Is there a cylinder key?
d) Is the pressure reading correct?
e) Is the cylinder colour code correct?
f) Are the hoses and fittings correct?
g) Is the system leaking?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Page 9
iv. RADIATION INTEGRITY TESTS

Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .

Radiation Integrity Tests Yes/done No/not done Corrected if applicable

a) Is the kV calibration correct?
b) Is the mAs calibrated correctly?
c) Was the line voltage compensation performed?
d) Was the exposure test correct?
e) Were the step wedge test results correct?
f) Were the small and large focus calibrations
done?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
v. PERFORMANCE TESTS (see manuals for manufacturer’s recommendations)
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .
Note: carry out all operational tests as specified by the manufacturer

Performance Tests Yes/done No/not done Corrected if applicable

a) Are the function verification tests correct?
b) Is the equipment calibration acceptable?

Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
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Page 10
FAULT REPORT (describe any shortcomings with the equipment or services provided)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . .
..............................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .
.....................................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
................................................................

NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .