Field Preventative Inspection Testing F1224 Rev 02

Customer Name: ___________________________________________________________

1733 W Parkside Lane Phoenix, AZ 85027 Ph: 623-780-2020 website: www.accutron-inc.com

Address: __________________________________________________________________

Step

Item / Function

1

Physical Check

2

Tubing and Rubber Goods

3,4

Leak Check 1 (outspout)

5,6

Leak Check 2 (air override, tubes, joints)

7

Non-rebreathing Replace non-rebreathing (outspout) leaf. No testing valve required.

9

Oxygen Flush

10

Failsafe Test

11

O2 Flow Point 1

12

O2 Flow Point 2

15,16 13,14

SN:

N2O Flow Point 1

17

Model#:

Percent N2O Control

Ball style (PC,DC,CM only) - O2 at 6 lpm and N2O at 6 lpm. Verify Nitrous % knob at 50% per procedure. (non-critical if flow tubes pass previous 4 test steps)

[ ] Return to Accutron for repair [ ] Customer chooses to keep unit and rely on flow tubes since %knob is only an aid. Customer Signature:

18

Pass (P) Fail (F)

Meter Desc:

O2 Resuscitator (100 lpm min)

Plug fixture into resuscitator outlet. Verify min flow in fixture

[ ] Return to Accutron for repair [ ] Customer chooses to keep unit, believes current flow meets emergency needs. Customer Signature:

N2O Flow Point 2

Final Status:

Requirement / Test Actions

Possible Corrective Actions if Test Fails

Check for damaged components (list parts here)

[ ] Non-critical (Cosmetic) damage, use as is [ ] Return to Accutron

Check for tears, cracks, holes, etc (list parts here)

[ ] Order parts (Remove from service until new parts arrive, no need for follow-up) ______________________________________________________________________

With gas supply connected and unit off, soap outspout

[ ] Return to Accutron for repair [ ] Customer keeping unit, is aware it might increase ambient levels of N2O in room and cause some gas loss. Customer Signature:

With gas supply connected and unit flowing 4 lpm of each gas, soap override in two places per procedure, (PC/DC only) test joints per procedure

[ ] Return to Accutron for repair [ ] Customer keeping unit, is aware it might increase ambient levels of N2O in room and cause some gas loss. Customer Signature: [ ] Non-rebreathing leaf replaced

Minimum flow of 20 lpm

[ ] Return to Accutron for repair [ ] Customer accepts Flush as is. Customer Signature:

Both gases to 4 lpm flow. Shut oxygen supply at source. Verify all flow stops (digital gives Failure Oxygen alarm)

[ ] Stop using and return to Accutron for repair

Ball style meters - O2 3 lpm. Verify fixture 3 lpm. Digital - Total Flow 3 lpm %N2O at 0. Verify fixture 3 lpm.

[ ] 1st test failed. Gas supply was low. After correcting supply unit passed retest. [ ] Proper flow could not be achieved, return to Accutron for repair

Ball style meters - O2 6 lpm. Verify fixture 6 lpm. Digital - Total Flow 6 lpm %N2O at 0. Verify fixture 6 lpm.

[ ] 1st test failed. Gas supply was low. After correcting supply unit passed retest. [ ] Proper flow could not be achieved, return to Accutron for repair

Ball Style - O2 3 lpm, N2O 3 lpm. Verify fixture 6 lpm. Digital - Total flow 6 lpm, %N2O 50%. Verify fixture 6 lpm. Ball Style - O2 6 lpm, N2O 6 lpm. Verify fixture 12 lpm. Digital - Total flow 9.9 lpm, %N2O 70%. Verify fixture 9.9 lpm.

[ ] 1st test failed. Gas supply was low. After correcting supply unit passed retest. [ ] Proper flow could not be achieved, return to Accutron for repair

[ ] Meets minimum requirements

Tested by: __________________________________ Date: _______________

[ ] 1st test failed. Gas supply was low. After correcting supply unit passed retest. [ ] Proper flow could not be achieved, return to Accutron for repair

[ ] Fails minimum requirements, return to Accutron for repair Test fixture # _________________ Fixture Calibration Due Date: __________________

Comments:

F 1224 rev02

CN#:CN-0646

Field Certification Test Sheet

Accutron, Inc. MASTER