CUSTOMER / CUSTOMER CONTACT
ADDRESS / CITY
STATE / DEPARTMENT
PHONE / EMAIL
BIOMED CONTACT / PHONE
DATE INITIATED / REQUESTED BY
DATE REQUESTED / DATE SCHEDULED
CASE MEDICAL SOLUTIONS SERVICE REQUISITION / MF# 52.1 Rev. B
PURPOSE
ASSESSMENT / EVALUATION / INSTALLATION / SERVICE CALL
SuperNova / Sink / Sonic / Washer / Cart Washer
Container / SteriTite / FlashTite / Loaners / In-Service

IF PARTS OR PRODUCTS ARE NEEDED, IDENTIFY BELOW

Product ID / Description / Estimated Time / Cost

IF INDEPENDENT SERVICE IS NEEDED, IDENTITY BELOW

VENDOR / NAME / CONTACT / PHONE / EMAIL / ASSIGNMENT
1
2
3
NOTES
APPROVED BY / DATE
ASSIGNED TO / DATE
Issued by: Tania Lupu
First Issue Date: 07/22/11
File: QC\Master Forms\MF# 52.1 Rev. A / Revision No. B
Changed by: MF Revision Date: 7/19/12
Verified & Approved by: TL Date: 7/20/12
CASE MEDICAL SOLUTIONS ASSESSMENT CHECKLIST / MF# 120.2 Rev. A
FOR MANUAL CLEANING
Sink / Brand / Part # / Photo
Brand / Part # / Photo
Brand / Part # / Photo
Current Product(s) Used:
Ultrasonic / Brand / Model # / Serial# / Setting / Cycle count
Brand / Model # / Serial# / Setting / Cycle count
Brand / Model # / Serial# / Setting / Cycle count
Brand / Model # / Serial# / Setting / Cycle count
Current Product(s) Used:
Washer / Brand/ Model # / Serial # / Setting / Cycle count
Brand/ Model # / Serial # / Setting / Cycle count
Brand/ Model # / Serial # / Setting / Cycle count
Brand/ Model # / Serial # / Setting / Cycle count
Brand/ Model # / Serial # / Setting / Cycle count
Brand/ Model # / Serial # / Setting / Cycle count
Brand/ Model # / Serial # / Setting / Cycle count
Current Product(s) Used:
Cart Washer / Brand / Model# / Serial # / Setting / Cycle count
Brand / Model# / Serial # / Setting / Cycle count
Brand / Model# / Serial # / Setting / Cycle count
Brand / Model# / Serial # / Setting / Cycle count
Current Product(s) Used:
ASSIGNED TO / DATE
APPROVED BY / DATE

TEST PERFORMED / RESULTS

Washer Indicator Name / Results / Water hardness level
Issued by: MF
First Issue Date: 09/21/12
File: QC\Master Forms\MF# 120.2 Rev A / Revision No. A
Changed by: Revision Date:
Verified & Approved by: TL Date: 9/21/12
CASE MEDICAL SOLUTIONS INSTALLATION CHECKLIST / MF# 120 Rev. F
OBTAIN PO
ORDER PRODUCT
GATHER PROPORTIONER, UNIVERSAL ADAPTER AND APPROPRIATE METERING TIP
GATHER APPROPRIATE COLOR CODED CAP AND ALARM STANDS (REGULAR FOR SINK WIDE MOUTH FOR MACHINE SET UP)
ESTABLISH DELIVERY DATE/ TIME LINE
COORDINATE WITH BIOMED PERSONNEL AT FACILITY
IDENTIFY EACH MACHINE MAKE AND MODEL
IDENTIFY SINK AND QUANTITY TO BE INSTALLED
PHOTOGRAPH THE SINK IF POSSIBLE ( DETERMINE IF THE ADAPTER IS NEEDED )
ENSURE THAT ALL PRODUCTS WERE RECEIVED
BRING TOOL KIT WITH WRENCH, ZIP TIES, TUBING, COLOR CODED TAPE, CHECK VALVE
VERIFY WATER QUALITY, TEMPERATURE, PH LEVEL, HARDNESS
IDENTIFY WHICH WASH INDICATOR IS USED
REFER TO WASHER MANUAL FOR TROUBLESHOOTING
BRING 1 GALLON SCHMUTZOFF TO DESCALE HIGHLY SOILED WASHERS IF NECESSARY
OBTAIN PACKING LIST
INSPECT ALL WASHER EQUIPMENT (SPRAY ARMS, DRAINS, WINDINGS, SCREENS ETC.)
COMPLETE MACHINE LOG SETTING FORMS (INTERNAL & EXTERNAL)
POST MACHINE SETTINGS
POST SINK AND SONIC SIGNS IF REQUESTED
INSERVICE STAFF
COMPLETE EVALUATION FORM, OBTAIN FEEDBACK
ORDER ADDITIONAL PRODUCT AS NEEDED
FOLLOW-UP
NOTES
OBSERVATIONS
SALES GOALS
ACTION ITEMS
RESULTS
COMPLETED BY / DATE
Issued by: Tania Lupu
First Issue Date: 07/22/11
File: QC\Master Forms\MF# 120 Rev F / Revision No. F
Changed by: MF Revision Date: 9/21/12
Verified & Approved by: TL Date: 9/21/12
CASE MEDICAL MACHINE SETTINGS FOR CUSTOMERS / MF# 147.1 Rev.A

MACHINE #

INSTRUMENT CYCLE / Temp / Time / Pump / Enz / Det / Lube Rate / Recirc
Pre Wash 1
Enzyme Wash
Sonic Wash
Rinse
Wash 1
Rinse 1
Thermal Rinse
Pure Water 1
Drying

MACHINE #

INSTRUMENT SHORT CYCLE / Temp / Time / Pump / Enz / Det / Lube Rate / Recirc
Pre Wash 1
Enzyme Wash
Sonic Wash
Rinse
Wash 1
Rinse 1
Thermal Rinse
Pure Water 1
Drying

MACHINE #

UTENSIL CYCLE / Temp / Time / Pump / Enz / Det / Lube Rate / Recirc
Pre Wash 1
Enzyme Wash
Sonic Wash
Rinse
Wash 1
Rinse 1
Thermal Rinse
Pure Water 1
Drying
Serviced By / Date
Approved By / Date
Recommendations
Issued by: Tania Lupu
First Issue Date: 07/22/11
File: QC\Master Forms\MF# 120 Rev E / Revision No. A
Changed by: MF Revision Date: 7/19/12
Verified & Approved by: TL Date: 7/20/12
CASE MEDICAL MACHINE LOG SETTINGS / MF# 147 Rev. D

MACHINE #

INSTRUMENT CYCLE / Temp
From To / Time
From To / Pump
From To / Enz / Det / Lube Rate
From To / Recirc.
Pre Wash 1
Enzyme Wash
Sonic Wash
Rinse
Wash 1
Rinse 1
Thermal Rinse
Pure Water 1
Drying
Serviced By / Date
Approved By / Date
Recommendations
Issued by: Tania Lupu
First Issue Date: 07/22/11
File: QC\Master Forms\MF# 120 Rev D / Revision No. D
Changed by: MF Revision Date: 7/19/12
Verified & Approved by: TL Date: 7/20/12
CASE MEDICAL FIELD REPORT / MF# 189 Rev.A

Complete all fields below. Rate interest level 1- 5 ( 5 representing high / hot )

PURPOSE
ASSESSMENT / EVALUATION / INSTALLATION / SALES CALL
GOALS
APPROVED BY / DATE
TERRITORY / REP / FACILITY
CONTACT INFO / PRODUCT FOCUS
INTEREST LEVEL / OPPORTUNITY / TIMELINE / $$
TERRITORY / REP / FACILITY
CONTACT INFO / PRODUCT FOCUS
INTEREST LEVEL / OPPORTUNITY / TIMELINE / $$
TERRITORY / REP / FACILITY
CONTACT INFO / PRODUCT FOCUS
INTEREST LEVEL / OPPORTUNITY / TIMELINE / $$
TERRITORY / REP / FACILITY
CONTACT INFO / PRODUCT FOCUS
INTEREST LEVEL / OPPORTUNITY / TIMELINE / $$
TERRITORY / REP / FACILITY
CONTACT INFO / PRODUCT FOCUS
INTEREST LEVEL / OPPORTUNITY / TIMELINE / $$
FIELD REPORT NOTES
OBSERVATIONS
SALES GOALS
ACTION ITEMS
SALES REP RATING
COMPLETED BY / DATE
Issued by: MF
First Issue Date: 09/21/12
File: QC\Master Forms\MF# 189 Rev A / Revision No. A
Changed by: Revision Date:
Verified & Approved by: TL Date: 9/21/12
CASE MEDICAL EVALUATION TRACKING FORM / MF# 101 Rev. C
PRODUCT EVALUATED
TIMELINE
CLINICAL / PRODUCT SPECIALIST
APPROVED BY / DATE
SOU / DATE / COMPLETED BY
PO / # / DATE / COMPLETED BY
PRODUCT SENT / DATE / COMPLETED BY
IN SERVICE STAFF / DATE / COMPLETED BY
IN SERVICE SPD / DATE / COMPLETED BY
IN SERVICE OR / DATE / COMPLETED BY
FOLLOW UP / DATE / COMPLETED BY
EVALUATION FORM / DATE / COMPLETED BY
NOTES
OBSERVATIONS
SALES GOALS
ACTION ITEMS
RESULTS
COMPLETED BY / DATE
Issued by: Tania Lupu
First Issue Date: 01/12/01
File: QC\Master Forms\MF# 101 Rev C / Revision No. C
Changed by: MF Revision Date:9/21/12
Verified & Approved by: TL Date: 9/21/12