ARJOHUNTLEIGH Maxi Sky Scales Instructions for Use rev 2 Jan 2014

Design Policy and Copyright ® and ™ are trademarks belonging to the ArjoHuntleigh group of companies. © ArjoHuntleigh 2012. As our policy is one of continuous improvement, we reserve the right to modify designs without prior notice.The content of this publication may not be copied either whole or in part without the consent of ArjoHuntleigh.

Table of Contents General Information ... 4 Forward... 4 Service and Support ... 4 Supplier Information... 4 Definitions Used in this Manual... 5 Intended Use... 5 Operational Life... 5 Equipment Identification... 5 Verifying the Package Contents upon Receipt ... 5 How to Use this Manual ... 5 Symbols Used... 6 Labels ... 6 Safety Instructions ... 7 Safety Instructions and Warnings ... 7 Human and Environmental Safety Practices ... 7 Equipment Description ... 8 Specifications for 700-00511 and 700-00526 scales ... 8 Specifications for Class III scales 700-00531 and 700-00536 ... 9 Specifications for 700-19485 and 700-19490 (Class III) scales... 10 Assembly Instructions ... 11 Scale models 700-00511 and 700-00531 ... 11 Attachment to track lift with conventional spreader bar... 11 Attachment to track lift with 4-point spreader bar ... 12 Attachment to compatible floor lift with conventional spreader bar ... 13

Scale model 700-00526 and 700-00536... 14 Attachment to track lift (LFXXXXX and 912XXXX models only) ... 14

Scale model 700-19485 and 700-19490... 15 Attachment to track lift with Quick-Connect spreader bar ... 15 Attaching the Scale to the Lift... 15 Attaching the Spreader Bar to the Scale ... 15

Operating Instructions ... 16 Weighing a patient ... 16 Weight Recall... 16 Units of Measure... 16 Calibration... 16 Care and Maintenance ... 17 Daily Checklist ... 17 Periodic Inspection ... 17 Scale Cleaning ... 17 Care of Accessories ... 17 Battery Replacement ... 17 Troubleshooting ... 18 Logbook ... 19 Non-Automatic Weighing Instruments ... 19

001-00545-EN rev. 2

Purpose of the Logbook ... 19 Responsibility of the Holder of the Equipment ... 19

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General Information Thank you for purchasing the ArjoHuntleigh Maxi Sky® scale. Your Maxi Sky scale is part of a series of quality products designed specially for home care, nursing homes and other health care uses. We are dedicated to serving your needs and providing the best products available along with training that will bring your staff the maximum benefit from every ArjoHuntleigh product. Please read this manual thoroughly, and contact us if you have any questions about the operation or maintenance of your ArjoHuntleigh equipment.

Forward Please read this manual in its entirety before using your ArjoHuntleigh Maxi Sky scale. The information in this manual is crucial to the proper operation and maintenance of the equipment, and will help protect your product as well as ensure that the equipment performs to your satisfaction. Lifting a person always presents a potential risk. Some of the information in this manual is important for your safety and must be read and understood to help prevent injuries. ArjoHuntleigh strongly advises and warns that to avoid injuries that can be attributed to the use of inadequate parts, only parts designated by ArjoHuntleigh should be used on equipment and other appliances supplied by ArjoHuntleigh. Furthermore, unauthorized modifications on any ArjoHuntleigh equipment may affect its safety. ArjoHuntleigh will not be held responsible for any accidents, incidents or deficiencies of performance that occur as a result of any unauthorized modification to its products.

Service and Support Always perform the required maintenance before using the scale. This will ensure the safety and good functioning of your product. See the “Care and Maintenance” section in this manual. If you require further information, please contact your local ArjoHuntleigh representative who can offer comprehensive support and service programs to maximize the long-term reliability, safety and value of the product. You could also contact your local ArjoHuntleigh representative for replacement parts. Your service representative stocks the parts you will need. Additional copies of this manual can be purchased from your local ArjoHuntleigh representative. When ordering, include the user manual product number (see front page) and equipment identification number.

Supplier Information

001-00545-EN rev. 2

This product has been manufactured by: ArjoHuntleigh AB Hans Michelsensgatan 10 211 20 Malmö SWEDEN

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General Information Definitions Used in this Manual WARNING:

WARNING: The manufacturer cannot ensure full safety for a scale of which the operational life has been exceeded.

Means: Failure to understand and follow these instructions may result in injury to yourself and others.

The expected life for other consumable products, such as batteries, fuses, slings, straps and cords is dependent upon the care and usage of the equipment concerned.

CAUTION:

Consumables must be maintained in accordance with published Instructions for Use.

Means: Failure to follow these instructions may cause damage to the product(s). NOTE:

Equipment Identification The unit's identification numbers (e.g. specification, model and serial number) appear on a label located on the back of the scale.

Means: This is important information regarding the correct use of the equipment.

Verifying the Package Contents upon Receipt

Intended Use

Upon receipt of the equipment, verify it against the packing list to ensure it is complete and inspect the equipment for possible damage due to shipping. If there is any damage, DO NOT USE the equipment and notify the carrier immediately to file a claim. Provide complete information concerning damage claims or shipping errors to your local ArjoHuntleigh representative. Include all equipment identification numbers and group part numbers (if any) as described above along with a full description of damaged parts.

The Maxi Sky scale is designed for weighing residents at acute care hospitals, care facilities for the elderly and other health care facilities, in accordance with the instructions for use outlined in this manual. Lifts equipped with a Maxi Sky scale have the added advantage of being able to weigh patients during transfers. The equipment must only be used for the purposes stated.

Operational Life

It is subject to preventive maintenance as specified in the “Care and Maintenance” section in this manual. The following table shows equivalent number of years in relation to wheighting cycles per day. One cycle is defined as weighting a load corresponding to scale’s SWL including a raising action (high enough to support the patient completely) setting the scale to provide a reading and a descending action.

Cycles per Day

Years (10,000 wheighting)

4

7

6

4.5

8

3.5

How to Use this Manual To ensure the safe operation of the Maxi Sky scale, read the entire manual carefully before installing, operating, or servicing this equipment. If anything is not completely understood, please contact your local ArjoHuntleigh representative for more details. Failure to comply with warnings in this manual may result in injuries. Keep this manual with the scale and refer to it as required. Make sure that all operators are regularly trained in the use of the equipment according to the information found therein. WARNING: Do not attempt to use this equipment without fully understanding the information contained in this manual.

001-00545-EN rev. 2

The Maxi Sky Scales as been designed and tested to achieve up to 10 000 weighting cycles at their respective safe working load.

5

General Information Symbols Used Symbol

Key to symbols

Symbol

This symbol is accompanied by the manufacturing date and manufacturer’s address.

Command button to set weighing unit of measure (kg/lb). Indicates that the scale is a non-automatic instrument; accuracy class 3.

Indicates the product complies with the medical device directive 93/42/EEC. This symbol is accompanied by the manufacturer's catalogue number. This symbol is accompanied by the manufacturer's serial number.

Key to symbols

IPN1N2

Degree of protection provided by enclosure. N1: Ingress of particles, N2: Ingress of water.

SWL

SWL represents the maximum load the lifter is rated for safe operation. Setup the lift ready for weighing the patient with the appropriate sling.

Indicates “separate collection” for all batteries and accumulators as per the WEEE Directive. Symbol refers to the Instructions for Use.

Lift patient for weighing.

Command button to display previously saved weight data.

Flashing display indicating negative readout value.

Command button to power the scale on or to zero the scale.

Labels Model # 700-00531 700-00536 700-19490

Model # 700-00511 700-00526 700-19485

Model #

Quick Guide

SWL

Certificate # SWL Load Cell Serial #

001-00545-EN rev. 2

Serial #

Model # Serial #

6

Quick Guide

Safety Instructions The equipment must be used in accordance with these safety instructions. Anyone using the equipment must also have read and understood the instructions in this manual. If there is anything you are not sure about, contact your local ArjoHuntleigh representative.

Safety Instructions and Warnings •

The Maxi Sky scale is specially designed for ArjoHuntleigh lift systems and accessories. Using the Maxi Sky scale with accessories designed by any other manufacturer is prohibited. Using only ArjoHuntleigh accessories will maintain the patient’s safety and the product’s functionality. WARNING: The Maxi Sky Scale is intended to be used for patients whose weight is within a specified safe working load. Do not attempt to lift more than the lowest weight limit indicated on the following: •

the track system;

•

the “maximum load” on the lift;

•

the “maximum load” label on the scale;

•

on the spreader bar;

•

on the sling.

•

DO NOT drop the scale. Dropping the scale may cause internal damage that is not easily seen. If you suspect the scale is damaged, contact an authorized technician for servicing.

•

Keep all components of the scale clean and dry, and have electrical and mechanical safety checkpoints performed as instructed in the "Care of your Scale" section of this manual.

•

Do not immerse.

•

Avoid violent impacts during transfers.

•

Class III scale models (700-00531, 700-00536 and 700-19490) must be verified, calibrated and sealed by certified personnel only. Contact your local dealer for more information about this requirement.

Human and Environmental Safety Practices

001-00545-EN rev. 2

For recycling and disposal of the battery, the rules according to the WEEE directive (Waste of Electronic and Electrical Components) as well as local regulations must be followed.

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Equipment Description Specifications for 700-00511 and 700-00526 scales 33 mm EXT.

46 mm EXT.

27 mm INT.

36.5 mm INT.

124 mm

128 mm

700-00526

001-00545-EN rev. 2

700-00511

8

•

Max. Weighting Capacity: 272 kg / 600 lb

•

Max. Weighting Capacity: 454 kg / 1000 lb

•

Accuracy / Display Resolution: 0.2 kg / 0.5 lb

•

Accuracy: / Display Resolution: 0.2 kg / 0.5 lb

•

Display Type: liquid crystal with 0.60" high characters

•

Display Type: liquid crystal with 0.60" high characters

•

Size: 65 mm (2 9/16") x 85 mm (3 3/8") x 116 mm (4 9/16")

•

Size: 65 mm (2 9/16") x 85 mm (3 3/8") x 116 mm (4 9/16")

•

Approx. weight: 0.88 kg / 1.9 lb

•

Approx. weight: 1.18 kg / 2.6 lb

•

Power supply: 9 Volts alkaline battery

•

Power supply: 9 Volts alkaline battery

•

Battery life: approx. 3000 readings

•

Battery life: approx. 3000 readings

•

Mode: kg or lb

•

Mode: kg or lb

•

Enclosure: ABS and Polycarbonate blend

•

Enclosure: ABS and Polycarbonate blend

•

Load cell degree of protection: IP67

•

Load cell degree of protection: IP67

•

Ambiant temprature range: Operation: 5 to 35°C Storage: -40 to 70°C

•

Ambiant temprature range: Operation: 5 to 35°C Storage: -40 to 70°C

•

Relative humidity range: Operation: 10 to 70% Storage: 10 to 70%

•

Relative humidity range: Operation: 10 to 70% Storage: 10 to 70%

•

Atmosphere pressure range: Operation: 700 to 1060 hPA (2000m max.) Storage: 500 to 1060 hPA (2000m max.)

•

Atmosphere pressure range: Operation: 700 to 1060 hPA (2000m max.) Storage: 500 to 1060 hPA (2000m max.)

Equipment Description Specifications for Class III scales 700-00531 and 700-00536 33 mm EXT.

46 mm EXT.

27 mm INT.

36.5 mm INT.

124 mm

128 mm

700-00536

700-00531 •

Max. Weighting Capacity: 272 kg

•

Max. Weighting Capacity: 454 kg

•

Accuracy / Display Resolution: 0.2 kg

•

Accuracy / Display Resolution: 0.5 kg

•

Display Type: liquid crystal with 0.60” high characters

•

Display Type: liquid crystal with 0.60” high characters

•

Size: 65 mm (2 9/16") x 85 mm (3 3/8") x 116 mm (4 9/16")

•

Size: 65 mm (2 9/16") x 85 mm (3 3/8") x 116 mm (4 9/16")

•

Approx. weight: 0.88 kg / 1.9 lb

•

Approx. weight: 1.18 kg

•

Power supply: 9 Volts alkaline battery

•

Power supply: 9 Volts alkaline battery

•

Battery life: approx. 3000 readings

•

Battery life: approx. 3000 readings

•

Mode: kg

•

Mode: kg

•

Enclosure: ABS and Polycarbonate blend

•

Enclosure: ABS and Polycarbonate blend

•

Load cell degree of protection: IP67

•

Load cell degree of protection: IP67

•

Ambiant temprature range: Operation: 5 to 35°C Storage: -40 to 70°C

•

Ambiant temprature range: Operation: 5 to 35°C Storage: -40 to 70°C

•

Relative humidity range: Operation: 10 to 70% Storage: 10 to 70%

•

Relative humidity range: Operation: 10 to 70% Storage: 10 to 70%

•

Atmosphere pressure range: Operation: 700 to 1060 hPA (2000m max.) Storage: 500 to 1060 hPA (2000m max.)

•

Atmosphere pressure range: Operation: 700 to 1060 hPA (2000m max.) Storage: 500 to 1060 hPA (2000m max.)

001-00545-EN rev. 2

CAUTION: CLASS III MODEL 700-00531 and 700-00536 scales must be verified, calibrated and sealed by certified personnel only. Contact your local dealer to get more details. NOTE: These scales meet all requirements according to EMC EN55022:1995 and EN45501, annex B:1994, N.A.W.I. EN45501:1994 and WEEE 2002/96/EC.

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Equipment Description Specifications for 700-19485 and 700-19490 (Class III) scales 52 mm EXT.

52 mm EXT.

156 mm

156 mm

001-00545-EN rev. 2

700-19485

700-19490

•

Max. Weighting Capacity: 272 kg / 600 lb

•

Max. Weighting Capacity: 272 kg

•

Accuracy / Display Resolution: 0.2 kg / 0.5 lb

•

Accuracy / Display Resolution: 0.2 kg

•

Display Type: liquid crystal with 0.60" high characters

•

Display Type: liquid crystal with 0.60” high characters

•

Size: 65 mm (2 9/16") x 85 mm (3 3/8") x 116 mm (4 9/16")

•

Size: 65 mm (2 9/16") x 85 mm (3 3/8") x 116 mm (4 9/16")

•

Approx. weight: 0.76 kg / 1.7 lb

•

Approx. weight: 0.76 kg

•

Power supply: 9 Volts alkaline battery

•

Power supply: 9 Volts alkaline battery

•

Battery life: approx. 3000 readings

•

Battery life: approx. 3000 readings

•

Mode: kg or lb

•

Mode: kg

•

Enclosure: ABS and Polycarbonate blend

•

Enclosure: ABS and Polycarbonate blend

•

Load cell degree of protection: IP67

•

Load cell degree of protection: IP67

•

Ambiant temprature range: Operation: 5 to 35°C Storage: -40 to 70°C

•

Ambiant temprature range: Operation: 5 to 35°C Storage: -40 to 70°C

•

Relative humidity range: Operation: 10 to 70% Storage: 10 to 70%

•

Relative humidity range: Operation: 10 to 70% Storage: 10 to 70%

•

Atmosphere pressure range: Operation: 700 to 1060 hPA (2000m max.) Storage: 500 to 1060 hPA (2000m max.)

•

Atmosphere pressure range: Operation: 700 to 1060 hPA (2000m max.) Storage: 500 to 1060 hPA (2000m max.)

CAUTION: CLASS III MODEL 700-19490 scale must be verified, calibrated and sealed by certified personnel only. Contact your local dealer to get more details. NOTE: CLASS III MODEL 700-19490 scale meet all requirements according to EMC EN55022:1995 and EN45501, annex B:1994, N.A.W.I. EN45501:1994 and WEEE 2002/96/EC. 10

Assembly Instructions Refer to the exploded view corresponding to your equipment for proper assembly instructions.

Scale models 700-00511 and 700-00531 Attachment to track lift with conventional spreader bar

Strap

000.00905 Ø7/16 x 1 21/32” clevis pin

000.00921 split ring

203.06151 Ø11 x 52 clevis pin 000.00921 split ring

Spreader bar

001-00545-EN rev. 2

WARNING: Make sure that all clevis pins are correctly secured by means of the split ring.

11

Assembly Instructions Attachment to track lift with 4-point spreader bar

203.06151 Ø11 x 52 clevis pin

000.00921 split ring

Spreader bar

001-00545-EN rev. 2

WARNING: Make sure that all clevis pins are correctly secured by means of the split ring.

12

Assembly Instructions Attachment to compatible floor lift with conventional spreader bar

000.00980 Nylon flat washer 1/2 x 1/16 T

203.06151 Ø11 x 52 clevis pin

000.00921 split ring

Spreader bar

001-00545-EN rev. 2

WARNING: Make sure that all clevis pins are correctly secured by means of the split ring.

13

Assembly Instructions Scale model 700-00526 and 700-00536 Attachment to track lift (LFXXXXX and 912XXXX models only)

000.04410 M10 locknut

000.04422 M10 plastic cap

000.04620 12 x 70 M10 shoulder bolt

000.04900 12 x 2.5T nylon flat washer

Scale

000.00902 3/8” x 1 3/4” clevis pin 000.00921 Split ring

Spreader bar

WARNING: Make sure that the clevis pin is correctly secured by means of the split ring and that the shoulder bolt is correctly secured by means of the M10 locknut tightened to a torque of 18 20 N•m.

001-00545-EN rev. 2

NOTE: Prior to installing the scale device on the track lift, remove the spreader bar block from the lift.

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Assembly Instructions Scale model 700-19485 and 700-19490 Attachment to track lift with Quick-Connect spreader bar Attaching the Scale to the Lift

Align the strap to the Quick-Connect door

Attaching the Spreader Bar to the Scale Align the Spreader bar Quick-Connect door to the Scale buttom hook

Pull the Spreader bar upward to insert the hook into the Quick-Connect Insert the strap into the Quick-Connect

Move the spreader bar to engage the hook into the pivot

Pull the strap upward to engage the pins into the pivot

Rotate the Spreader into position

Note that the door will close

Note that the door will close

Do not operate the lift if the door remains open

Do not operate the lift if the door remains open

001-00545-EN rev. 2

Rotate the strap into position

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Operating Instructions Weighing a patient

Calibration

1) Connect the sling to the spreader bar and press the ON/ZERO pad to zero the scale. Make sure no part of the sling or spreader bar is touching the floor or any surrounding object.

(Models 700-00511, 700-00526 and 700-19485 only)

2) Place the sling around the patient. Lift the patient clear of the bed or chair in accordance with the lift manufacturer’s instructions. 3) Read the patient’s weight on the display. If the display turns off before lifting the patient, press the ON/ZERO pad to turn the scale on and continue weighing. 4) When weighing is complete, lower the patient.

Weight Recall A few conditions must be met for this feature to function: 1) The scale must be on. Press the ON/ZERO pad. 2) The saved weight measurement must be greater than the value indicated on the scale’s label. 3) The display must show a “HOLD” icon during the weighing procedure for it to save the load measurement. If these conditions are met, then press the RECALL pad to display the last weight taken. NOTE: If the display flashes, or the “-” appears, it means that the weight shown is negative. NOTE: The display turns off after three minutes of inactivity.

Units of Measure (Models 700-00511, 700-00526 and 700-19485 only) To change the unit of measure from pounds (lb) to kilograms (kg) or vice versa: 1) Press the LB/KG pad. The display will show the “CONV” symbol.

001-00545-EN rev. 2

2) Hold the pad down until the “CONV” symbol diseapear.

16

CAUTION: CLASS III MODEL 700-00531, 700-19490 and 700-00536 scales must be verified, calibrated and sealed by certified personnel only. Contact your local dealer to get more details. Scale calibration must be performed at least once a year. A 25 lb (10 kg) precision weight is required to perform the procedure. Do not use packaged goods, fitness weights or other items labelled “25 lb (10 kg). Failure to use a precision weight may cause the scale to display an inaccurate weight. Using a certified weight is the preferred method. 1) To enter the calibration mode, press the ON/ ZERO pad. While holding it, press and hold the LB/KG pad. After approximately 3 seconds the message on the display will change from ZERO to CAL0. Release both pads and the display will show C0. 2) Make sure the sling is empty and stabilized prior to pressing the ON/ZERO pad. The display will count down from “8” to “0”. When finished, the display will show “C25”. 3) Place the 25 lb (10 kg) precision weight in the sling and let it stabilize. Press the ON/ZERO pad once again. The display will count down from “8” to “0” as before. The display will then return to the weighing mode. Calibration is complete. 4) Remove the 25 lb (10 kg) precision weight, stabilize the sling, and press the ON/ZERO pad to zero the scale. The scale is ready for use. NOTE: Failure to stabilize the unit may cause the scale to display an inaccurate weight or to impede calibration. Wait until it stops bouncing or swinging before pressing the ON/ZERO button. When placing the weight into the sling, make sure it is centered directly below the scale.

Care and Maintenance Daily Checklist

Battery Replacement

Following procedure must be followed befored each use:

If the battery symbol appears on the display, it means that the battery will need replacing. The battery compartment is located behind the scale.

•

Ensure that all the split rings, bolts and QuickConnect attachments that attach the spreader bar or the strap are secured.

•

Inspect the enclosure for any sings of craking or damages. If this is the case, do not use the scale, contact your Arjohuntleigh representative to have it serviced.

•

Pay attention to the “Low Battery” symbol on the display and replace the batteries accordingly.

Battery compartement cover

Periodic Inspection A visual inspections of the scale attachment bolts and brackets is required once a mounth to ensure they are firmly tightened and with no wear. CAUTION: Class III scale models 700-00531, 700-00536 and 700-19490 must be verified, calibrated and sealed by certified personnel only. Contact your local dealer to get more details about this preliminary requirement.

Scale Cleaning

To replace the battery: 1) Push down and slightly forward on the battery compartement cover. The cover will slide forward and disengage. Remove the cover and pull out the battery holder. 2) Replace the existing battery with a new, 9-volt alkaline battery and slide the battery holder back into the compartment. Secure the battery compartment cover into place by pushing it down and back into position.

To clean the scale, wipe it down with a damp cloth using warm water and a disinfectant cleaner. If the scale is found to be contaminated, wipe the scale completely with hard surface disinfectant wipes which are supplied already impregnated with a 70% v/v solution of isopropyl alcohol. Rub the equipment vigorously when using the wipes, to promote an effective disinfection of its entire surface. CAUTION: Do not use disinfectant with more than 0.5% w/w hydrogen peroxide; as it may damage product labeling.

Care of Accessories

001-00545-EN rev. 2

Other than cleaning, no user maintenance is required, but some components may need to be replaced during the product’s lifespan. This should be carried out by an Arjohuntleigh qualified technician. For more information, contact ArjoHuntleigh or an authorized distributor.

17

Troubleshooting Trouble

Resolution • •

Replace battery. Check for external damage, if there is, call ArjoHuntleigh for servicing.

Display flashes or shows “-” with no load.

•

Press

Display shows a battery symbol.

•

Replace battery.

Loose bolts or loose top/bottom attachments.

•

Call ArjoHuntleigh for servicing.

Unit of measure setting button does not work.

• •

Maintain the button pressed for at least 3 seconds. For a defective membrane, call ArjoHuntleigh for servicing.

001-00545-EN rev. 2

Scale does not turn on.

18

to reset to zero.

Logbook Non-Automatic Weighing Instruments Verification interval (years): CustomerName and address (the end user):

Scale model:

700-00511  700-00526  700-19485 

700-00531  700-00536  700-19490 

Scale serial number: Classification of the scale:

Purpose of the Logbook •

The logbook retains all the information relevant to the inspection, repair or modification of the instrument.

•

The logbook can be provided by ArjoHuntleigh, the approved inspector or the approved repair engineer.

•

The logbook must accompany the scale at the place of use.

•

The logbook must always accompany the scale, even if the scale is mobile.

Responsibility of the Holder of the Equipment •

The holder (end user) must make this logbook available at all times for the local regulatory authority, the approved inspector or the approved engineer.

•

The responsibility for producing the logbook lies with the holder (end user) of the scale.

•

The holder (end user) is responsible for looking after the integrity of the logbook.

•

The absence of logbook or damages made to the logbook will result in refusal to sign for the periodic verification or the refusal of an approved engineer to work on the scale.

•

If a logbook replaces another one, the approved inspector or the approved engineer must note this on the new logbook.

•

The holder (end user) is responsible to ensure that the approved bodies for verification fill in the logbook and should sign the logbook after the signature of the approved inspector or the approved engineer. Initial verification  Date work completed (DD/MM/YY):

___ ___ / ___ ___ / ___ ___

Verification body (models 700-00531, 700-00536 and 700-19490 only): Identification of the organization – service provider (name and address): Represented by:

001-00545-EN rev. 2

Signature of organization – service provider:

19

Logbook Nature of work carried out

 Periodic verification

 Repair (maintenance) – calibration

Date work completed (DD/MM/YY):

 Modification

___ ___ / ___ ___ / ___ ___

Identification of the organization – service provider:

Name and address:

Represented by:

Signature of organization – service provider: Signature of holder (end user):

 Approved  Refused

Verdict of the verification:

Nature of work carried out

 Periodic verification

 Repair (maintenance) – calibration

Date work completed (DD/MM/YY):

 Modification

___ ___ / ___ ___ / ___ ___

Identification of the organization – service provider:

Name and address:

Represented by:

Signature of organization – service provider: Signature of holder (end user):

001-00545-EN rev. 2

Verdict of the verification:

20

 Approved  Refused