Attachment 1 DRAFT Statement of Work_Lab Equipment Maintenance BPA.pdf

STATEMENT OF WORK

MEDICAL DEVICE AND SYSTEMS MAINTENANCE

I. Introduction

The Uniformed Services University of the Health Sciences (USUHS) is the Nation's federal health sciences university and is committed to excellence in military medicine and public health during peace and war. As a medical school, which includes several multi-disciplinary research laboratories, USUHS requires services for preventive maintenance (PM) and remedial repair of various Medical Devices/Medical Device Systems (MD/MDS), refer to the attached equipment list.

II. Scope of Services

The contractor shall provide all necessary services, qualified personnel, materials, facilities, and equipment not otherwise provided by the Government as needed to perform the work described below:

The vendor must provide a flexible method for acquiring preventive maintenance and remedial repair services, management of preventive maintenance and remedial repair services, and optional services for services on a full spectrum of equipment and systems utilized at USU. The vendor should streamline and integrate the maintenance processes for efficient, expedient, and cost-effective Medical Devices/Medical Device Systems (MD/MDS) maintenance and repair services.

The vendor shall provide all labor, material, supplies, tools, diagnostic software, and test equipment to perform MD/MDS maintenance and repair services at the USUHS. The services will be performed on select equipment identified in the attached equipment list.

The vendor must provide technical, application, and operational support to Government personnel on an as needed basis via phone, on site, or other means applicable to the requirements of the work order. Generally, telecommuting is not feasible for the services provided under this action, medical equipment maintenance, administrative, and professional support services must be performed on site.

The vendor will provide maintenance service, including diagnostic services, preventive maintenance (PM), instrument service agreements (ISA) for highest priority core instruments, relocation services and emergency (remedial) repairs on items for which an order is issued under this blanket purchase agreement (BPA).

The vendor must schedule preventative (PM) visits in accordance with the original equipment manufacturer’s (OEM) recommendation. Additionally, the vendor must maintain records to track and initiate all PM visits and shall not assume the Government will request or remind when PMs are due. All work must be completed in accordance with the OEMs' specifications and operability.

The vendor must be available to respond to all service calls as quickly as possible, ideally within one (1) business day. All repairs be completed as expeditiously as possible to minimize downtime. The vendor must meet its own proposed response and repair timelines in accordance with the quote provided at the time of the work order. A designated contractor representative shall be available for Government contact via email and telephone, 24 hours a day, seven (7) days a week, to include holidays. Maintenance services shall be provided in accordance with section 6. Regular Maintenance shall take place from 0730 to 1600.

The vendor must be available to speak directly with the service providers and technicians to troubleshoot over the phone to resolve minor issues and/or to streamline the service call process by verbally discussing issues to the technician.

If required, the vendor must contact the USU Technical Service Branch (TSB) to schedule an inspection/recertification visit within 60 days of the receipt of a work order. The recertification must be completed in accordance with the OEM specifications and operability. If recertified by a third-party

DRAFT

independent service provider (TSP), the recertification must be approved by the OEM. USU will not duplicate the recertification effort by multiple vendors. All vendor-supplied instruments used to service the instruments must be Nation Institute of Standards and Technology (NIST) certified.

All work must be performed in accordance with Federal, State, and local regulations to include, but not limited to CAP, CFR (FD&C ACT), Hazardous waste, OSHA Electrical Standards, Maryland Department of Health, ANSI/AAMI/ISO etc.

III. Maintenance Requirements

Medical Devices/Medical Device Systems

Medical devices/medical device systems consist of devices used in the medical diagnosis, therapy, and treatment of injury or disease (includes dental, aeromedical evacuation, Home Station Medical Response, and veterinary items). Medical devices/medical device systems also consist of commercial off-the-shelf (COTS) equipment and device systems approved by the Food and Drug Administration and used primarily in Medical Treatment Facilities (MTFs) or Research Facility to provide/implement research/patient care. Lastly, medical devices/medical device systems also refers to any maintenance significant instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part or accessory and is:

1. Intended for use in the research, diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals.

2. Intended to affect the structure or any function of the body of man or other animals, and which does not achieve any of its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of any of its primary intended purposes.

MD/MDS include but are not limited to:

Unscheduled Routine Maintenance. These services are non-emergent and performed on a non-recurring, one-time basis. Unscheduled routine maintenance includes the services required to restore equipment within the manufacturer’s specifications. It includes all services required due to minor or major malfunctions, or due to damage to the equipment by accident, neglect, abuse, power surge, power failure, or operation in an environment not compatible with the equipment’s published specifications, unless such damage is caused by the CSP. Unscheduled routine maintenance includes the inspection, testing, troubleshooting, servicing, re-calibration (if incidental to repair), and all other actions necessary to return the item to a fully serviceable state. Unscheduled routine maintenance services may include relocation with installation and de-installation of equipment.

Unscheduled Urgent Maintenance. These services are urgent, time-limited and are performed on a non-recurring, one-time basis. Unscheduled urgent MD/MDS work requests are required for repair of a unit’s or activity’s mission essential MD/MDS as soon as possible. Without these MD/MDS, the activity’s ability to perform the assigned operational mission is impaired resulting in decreased healthcare efficiency, patient access, and/or quality of care. Unscheduled urgent maintenance includes the inspection, testing, troubleshooting, servicing, re-calibration (if incidental to repair), and all other actions necessary to return the item to a fully serviceable state.

Unscheduled Emergency Maintenance. These services are emergent, time-limited and are performed on a non-recurring, one-time basis. Unscheduled emergency MD/MDS work requests are required for immediate repair of a unit’s or activity’s mission essential MD/MDS. Without these MD/MDS, the activity is unable to perform the assigned mission(s). Loss of MD/MDS functionality prevents patients access to health care resulting in cancellation, deferment, and/or rescheduling of all medical appointments and/or procedures (e.g., CT becomes non- mission capable (NMC) and patients are diverted to another facility outside the network.) Unscheduled emergency maintenance includes the inspection, testing, troubleshooting, servicing, re-calibration (if incidental to repair), and all other actions necessary to return the item to a fully serviceable state.

Preventive Maintenance. Preventive Maintenance (PM) is the scheduled care, servicing, inspection, detection, and correction of minor faults before these faults develop to become unscheduled services actions. PM is performed in an attempt to retain an item in a specified condition by providing systematic inspection, detection, and prevention of incipient failures.

Preventive Maintenance Checks and Services. PMCS are the systematic care, servicing, and inspection of MD

Repair. Return the device or component to OEM specifications as approved by the FDA including replacing non-working components or parts outside of routine or periodic upkeep.

Field Service Report (FSR). Written service report providing detailed information regarding the cause of equipment malfunction and corrective action taken, to include the time required to complete the work, price of labor (hourly rate), a list of parts replaced with the cost of each part.

Inspection. Inspection encompasses both electrical safety and performance inspection actions.

Inspections ensure that impacted devices perform in accordance with Original Equipment Manufacturer (OEM) design specifications.

Calibration, Serification, and Certification (CSC). Services to determine compliance of MD/MDS with applicable specifications or standards and to make the necessary corrections or to compare items with certified device, tool, or test equipment traceable to National Institute Standards and Technology (NIST) standards

Materials are defined as direct materials, including supplies transferred between divisions, subsidiaries, or affiliates of the contractor under a common control; subcontracts for supplies (e.g., repair parts) and incidental services for which there is not a labor category specified in the contract; other direct costs (e.g., incidental services for which there is not a labor category specified in the contract); subcontracts for services which are specifically excluded from the hourly rate; and indirect costs. If the contractor furnishes materials that meet the definition of a commercial item at FAR 2.101, the price to be paid for such materials shall not exceed the contractor’s established catalog or market price, adjusted to reflect the quantities being acquired. To the extent able, the contractor shall obtain materials at the most advantageous prices available with due regard to securing prompt delivery of satisfactory materials and give credit to the Government for cash and trade discounts, rebates, scrap, commissions, and other amounts that are identifiable.

Maintenance Scheduling

As described in the maintenance definitions above, the vendor must adhere to the following timelines for completing the required maintenance and/or repairs as outlined in the table blow:

Description Work Order Initiation

Work Order Confirmed by

Contractor

Work Order Scheduled Contractor On Site

Scheduled Routine

Direct contact by BPA Caller and/or TPOC

Via email within one (1) business day of notification

Within three

(3) business days of confirmation

Within 20 calendar days of confirmation

Unscheduled Routine

Direct contact by BPA Caller and/or TPOC

Via email within two (2) hours of notification during normal operational hours

Within one (1) business day of confirmation

Within 101 business days of confirmation

Unscheduled Urgent

Direct contact by BPA Caller and/or TPOC contractor-provided“Hotline”4

Confirmed and Scheduled via email within two (2) hours of notification

Within 48 hours2 of initiation

Unscheduled Emergency

Direct contact by BPA Caller and/or TPOC contractor-provided“Hotline”4

Confirmed and Scheduled via “Hotline” at time of initiation

Within 24 hours3 of initiation

1. If the contractor is unable to complete within 10 business days, the contractor shall notify the Task Order COR/ACOR via email of the reason and negotiate resolution/new schedule.

2. If the contractor is unable to complete within 48 hours of initiation, the contractor shall directly notify the Task Order COR/ACOR via phone call of the reason and negotiate resolution /new schedule.

3. If the contractor is unable to complete within 24 hours of initiation, the contractor shall directly notify the Task Order COR/ACOR via phone call of the reason and negotiate resolution /new schedule.

4. Hotline shall be operational 24 hours a day, seven (7) days a week.

Quality Control

The contractor shall maintain an industry quality standard-compliant process such as ISO 9000 or equivalent.

Repair Parts

The contractor shall provide repair parts associated with the maintenance or repair actions described in TABLE 1: DESCRIPTION AND REQUIREMENTS FOR MD/MDS SERVICES. Repair parts include replacement of parts of components or modules of MD/MDS or OEM approved modifications to

MD/MDS.

The contractor shall provide routine and emergency repair parts not associated with a contractor or subcontractor/preferred vendor maintenance action or service.

Routine and emergency repair parts purchased specifically for, and are identifiable solely with, performance under this BPA, shall not exceed the contractor’s established catalog or market price, adjusted to reflect the quantities being acquired.

Routine Repair Parts. With the direction of the Technical POC and/or COR, the Authorized BPA Caller shall contact the contractor to initiate a work order. The Contractor shall provide acknowledgement (work order confirmation) in writing via email of the Government’s work order within one (1) business day. The contractor shall order routine repair parts within two (2) business days of acknowledgement of the work order. Once the order has been placed, the contractor shall provide a timeline and tracking number to the BPA Caller and Technical POC.

Emergency Repair Parts. With the direction of the Technical POC and/or COR, the Authorized BPA Caller shall initiate an emergency part work order directly (person-to-person) to the contractor via a “Hotline” or equivalent. Contractor shall order emergency parts within two (2) hours of direct communication. Once the order has been placed, the contractor vendor shall provide a timeline and tracking number to the BPA Caller and Technical POC. The Government will reimburse the contractor for the expedited shipping costs for emergency repair parts.

New or Certified Refurbished Parts. The contractor shall provide only OEM new or OEM certified refurbished parts. All refurbished parts shall be certified as meeting the OEM’s minimum requirements.

Certified refurbished parts must be approved on a work order basis by the BPA Caller and Technical

POC.

Repair of MD/MDS by Replacement. A MD/MDS may be replaced with a new or OEM certified refurbished MD/MDS of the same manufacturer and model with the same options and features with approval of the Task Order COR/ACOR in the following situations:

1. When the required repair equals or exceeds the cost of a new or OEM certified refurbished

MD/MDS.

2. When OEM or OEM certified refurbished parts are no longer available for repair.

3. When the OEM's standard operating procedure for the MD/MDS is repaired by replacement.

Software

The contractor shall furnish, or have access to, all necessary diagnostic software to include software updates (required application software patches/bug fixes, operating system patches, and modifications resulting from recall or hazard alerts) issued by the OEM. If it is a different version than currently installed, the contractor shall notify the TPOC prior to uploading software applications, patches, or modifications to medical devices. Only manufacturer approved patches shall be installed on Government medical devices/systems.

For network connected devices, only Information Assurance (IA)- approved software versions shall be installed on any MD/MDS. The contractor shall provide the TPOC any hard drives, DSDs, CDs, USBs, etc. used to transfer data (software, patches, drivers, etc.) to a MD/MDS for pre-scanning viruses prior to the data transfer. If maintenance includes any software installation to a MD/MDS, the contractor shall perform a full functions check on the MD/MDS upon completion of services.

The use of remote, business-to-business (B2B) connections must be through the TPOC and USU approved connections/gateways.

Inspection and Acceptance

The vendor shall only tender for acceptance those items that conform to the requirements outlined within the Statement of Work. The Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance.

The Government may require repair or replacement of nonconforming supplies or re-performance of nonconforming services at no additional charge. If repair and/or replacement or re-performance will not correct the defects or is impossible, the Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The Government must exercise its post-acceptance rights:

1. Within a reasonable time after the defect was discovered or should have been discovered, and

2. Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item.

Documentation of Work

The Government is responsible for all documentation of equipment maintenance except for the vendor or preferred vendor-provided Field Service Report and FDA Form 2579 (Report of Assembly of a Diagnostic X–Ray System), when applicable.

The vendor shall maintain a 24 x 7 secure website or portal for Government access to detailed service information such as maintenance history reports (field service reports), program transactions, equipment maintenance activity, status of service, and vendor usage reports. The maintenance program data is available via downloadable reports. The website shall provide a web-based problem tracking system for authorized Government representatives to query, review, update, and track calls for all maintenance services.

The contractor shall comply with FDA regulations for submission of FDA Form 2579, Report of Assembly of a Diagnostic X-Ray System, and submit a copy with the field service report (FSR) for the installation of certified components (e.g., x-ray or CT tubes, collimators, etc.) The contractor or preferred vendor shall also upload the FDA 2579 and Field Service Report to the contractor’s website within three

(3) business days of completion of work order.

The contractor shall complete DD Form 2164 (X-ray Verification/Certification Worksheet) in accordance with the instructions provided in USU INST 4144, refer to Attachment 1. A continuation sheet shall be attached to the DD Form 2164 indicating the manufacturer, model, serial number, and date of calibration expiration of all items of test, measurement and diagnostic equipment (TMDE) used to perform the calibration. If the contractor's calibration equipment produces a printed summary of the calibration procedure used, the printed summary will be attached to the DD Form 2164. The contractor shall ensure that the heading of the DD Form 2164 is filled out and that the form is properly signed.

The vendor shall sign all proof of documentation and calibration documents and uploaded to the contractor’s website within three (3) business days of completion of work order. The contractor’s documentation shall contain, at a minimum, the required data elements of DD Form 2164, Vendor's Verification/Certification Worksheet (VVCWS), refer to Attachment 2. Proof of work completed or calibrated shall contain the manufacturer, model, serial number, and date of calibration expiration of all items of test, measurement and diagnostic equipment used to perform the calibration. If the contractor’s calibration equipment produces a printed summary of the calibration procedure used, the contractor shall upload the printed summary to the contractor’s website.

IV. Contractor Qualification Requirements

The contractor shall be solely responsible for obtaining all necessary licenses and permits, and for complying with all applicable Federal, State and local laws, codes, and regulations in connection with the execution of the work to be performed. Additionally, the contractor shall be solely responsible for providing preventive maintenance and repair services according to original equipment manufacturer specifications for equipment.

V. Scheduling

The contractor must provide service during normal business hours Monday through Friday from 7:30am ET (0730 hours) to 4:00pm ET (1600 hours). Premium pricing for services outside the normal business hour and special arrangements must be included in the contractor’s price listing. The contractor may be required to perform services on days designated as a Federal Holiday by Federal Status, Executive Order, Presidential Proclamation or Installation Commander as required. The following is a list of legal federal holidays on which the contractor may be required to perform services:

New Year’s Day Labor Day Martin Luther King, Jr. Day Columbus Day Washington’s Birthday Veterans Day Memorial Day Thanksgiving Day Independence Day Christmas Day Juneteenth

VI. Delivery Locations

Uniformed Services University of the Health Sciences (USU) USU Receiving Dock 4301 Jones Bridge Road Bethesda, MD 20814-4799 FOB: Destination

VII. Transportation and Installation Access

All vehicles and drivers must meet Naval Support Activity (NSA) Bethesda base access requirements. The contractor shall assure that all vehicles are properly registered and that operators are currently licensed for the class of vehicle being operated.

The contractor is highly encouraged to enroll in the long-term RAPIDGate pre-vetted base access. Delayed or failure to perform due to contractor's negligence in ensuring base access will not be permitted as an excusable delay. The contractor must ensure that its personnel are able to obtain US military base access and must coordinate with the Technical Point of Contact (TPOC) to obtain base and parking access.

VIII. Insurance

Pursuant to the FAR Clause, 52.228-5, the Contractor shall be required to present evidence to show, as a minimum, the amounts of insurance coverage indicated below:

Worker's Compensation and Employer's Liability.

The Contractor is required to comply with applicable Federal and State workers' compensation and occupational disease statutes. If occupational diseases are not compensable under those statutes, they shall be covered under the employer's liability section of the insurance policy, unless contract operations are so commingled with the contractor's commercial operations that it would not be practical to require this coverage. Employer's liability coverage of at least $100,000.00 shall be required, except in states with compensation to be written by private carriers.

General Liability.

The Contractor shall have bodily injury liability insurance coverage written on the comprehensive form of policy of at least $500,000 per occurrence.

Property Damage liability insurance shall be required in the amount of $500,000.

Automobile Liability.

The Contractor shall have automobile liability insurance written on the comprehensive form of the policy. The policy shall provide for bodily injury and property damage liability covering the operation of all automobiles used in connection with performing the contract. Policies covering the vehicles operated in the United States shall provide coverage of at least $200,000 per person; $500,000 per occurrence for bodily injury and $100,000 for property damage. The amount of liability coverage on other policies shall be commensurate with any legal requirements of the locality and sufficient to meet normal and customary claims.

IX. Deliverables

The contractor shall complete and submit deliverables in accordance with the “Deliverables Table” below. Unless specified in the PWS within the description of the deliverable, all deliverables will be made to the COR electronically.

Number Title/Description Due

Deliverable 1 Annual Reports The Contractor shall provide annual reports that detail maintenance costs by individual pieces of equipment. This shall include one report per year detailing each piece of equipment by activity. Report detail shall include at a minimum preventive maintenance, labor, cost of parts, services performed, etc.

Within 45 days of the end of the current performance period.

Deliverable 2 Year-to-Date Statistical Information Reports Upon request by the using activity, the Contractor shall provide year-to-date reports that detail maintenance costs by piece of equipment.

Within two business days of request.

Deliverable 3 Quotes In response to a Government request for a quote, the Contractor shall provide a quote to the activity.

Within 10 calendar days of request.

Deliverable 4 Monthly Financial Tracking Report The contractor shall provide a spreadsheet with detail of real time expenditure levels of every contract line item number (CLIN).

Within 45 days after contract award and monthly thereafter.

Deliverable 5 Monthly Report The contractor shall provide a monthly report detailing all work, including the subcontractor’s work, and where there is critical or significant data related to the provided support.

No later than the 15th day of each month for the preceding month.

Deliverable 6 Post-Award Conference/Periodic Progress Meetings The contractor shall attend the post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. The Task Order-level COR may meet periodically (but not less than quarterly) with the contractor to review the contractor’s performance.

Contractor shall attend progress meetings no less than one per quarter.

Deliverable 7 Inventory detailing Government Furnished Equipment/Material or Contractor- Acquired Government Owned Property (CAP) To be attached to the Monthly Progress Report

No later than the 15th day of each month for the preceding month.

Deliverable 8 Information Security Program Training The contractor shall ensure all service providers receive Information Security Program training.

No later than 30 days after contractor personnel begin performance under this contract, and annually thereafter.

Deliverable 9 Visit Report The Contractor shall provide a trip report to include costs associated with the travel to the COR

No later than 10 days following Visit completion.

Deliverable 10 Field Service Report (FSR) Completed upon completion of each servicing event.

X. Quality Assurance Surveillance Plan (QASP)

The Contractor’s performance will be assessed based on the following measures:

Task/Performance Objective Performance Standard &

Acceptable Performance level

(AQL)

Method of Surveillance

No later than 60 days after contract award, the vendor shall maintain a national, centralized network of

Maintain a national, centralized network of qualified subcontractors/ preferred vendors based upon the medical

Periodic and random inspections on monthly, quarterly, or as needed basis.

Customer complaint and/or subcontractors/preferred vendors capable of providing maintenance and repair services required in

SOW.

device/medical device systems’ manufacturers.

AQL: 95%

review of other available reports.

The contractor shall ensure qualifications of technicians dispatched by the vendor to perform work on a specific MD/MDS shall match the level of service requirement indicated in SOW for the equipment being serviced.

As stated in the Statement of Work. AQL: 100%

Customer complaint and/or review of other available reports.

Provide all required documents as outlined within the Statement of Work and BPA Ordering Instructions and within the required timelines to the Tech POC (e.g. shipping documentation, etc.).

Provides all reports via email to the Tech POC for all services performed. AQL: 99%.

Customer complaint and/or review of other available reports.

Ensure compliance with all safety and insurance requirements set forth in applicable State, Federal, and Local Laws and Regulations.

As stated in the Statement of Work. AQL: 99%.

Customer complaint and/or review of other available reports.

Provide Scheduled and Unscheduled Routine, Unscheduled Urgent, and Unscheduled Emergency maintenance services and associated repair parts as contracted.

As stated in the Statement of Work. AQL: 99%.

Customer complaint and/or review of other available reports.

XI. Attachments

Attachment 1: Equipment List Attachment 2: USUHS INST 4144 Attachment 3: DoD Form DD2164

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2164, NOV 78

X-RAY VERIFICATION/CERTIFICATION WORKSHEET

(Use additional sheet for remarks. Identify item by number.)

ACTION

REQUIRED NOT REQUIRED TAKEN

LOCATION (Include Building and Room Number) DATE AND TIME OF SERVICE DATE NEXT SERVICE DUE

I. EQUIPMENT IDENTIFICATION

COMPONENTS MANUFACTURER MODEL

(Include type, style, size, focal spots, etc.)

SERIAL NUMBER

(Housing)

1. CONTROL NO. 1

(Master Control)

2. CONTROL NO. 2

(Room Control)

3. RADIOGRAPHIC TUBE

4. RADIOGRAPHIC TUBE

(Auxiliary tube)

5. FLUOROSCOPIC TUBE

II. VISUAL INSPECTION OF EQUIPMENT

ITEMS FOR VISUAL INSPECTION

ACTION

NOT

REQUIRED TYPE REQUIRED ACTION

TAKEN

INITIAL AND

DATE

6. CERTIFICATION LABELS ARE AFFIXED AND VISIBLE

7. STEEL COUNTERWEIGHT CABLES

8. SHOCK-PROOF HIGH TENSION CABLES

9. TUBE HANGER ASSEMBLY AND YOKES

10. INDICATOR LIGHTS

11. X-RAY TUBES FOR OIL LEAKS

III. OPERATIONAL TESTING OF EQUIPMENT

ITEMS FOR VISUAL INSPECTION

ACTION

NOT

REQUIRED TYPE REQUIRED ACTION

TAKEN

INITIAL AND

DATE

12. INTERLOCKS

13. LOCKS

14. BACKUP SAFETY TIMERS

15. TABLE AND TUBESTAND MOTION

16. BEAM LIMITING DEVICES (Manual and automatic mode)

17. TABLE ANGULATION LIMIT SWITCHES

18. DOES TUBE OVERLOAD PROTECTION CIRCUIT DISABLE EXPOSURE CIRCUIT? YES NO

19. IS THE PRODUCTION OF X-RAYS INHIBITED UNTIL ANODE IS UP TO SPEED? YES NO

20. DOES BRAKE ON HIGH SPEED STATOR OPERATE CORRECTLY?

(Record coast down time for anode after exposure ) YES NO

IV. RADIOGRAPHIC CERTIFICATION

21. SINGLE PHASE LINE VOLTAGE AND LINE DROP

NO LOAD LINE VOLTAGE VOLTS

A. L 1 TO GROUND

B. L 2 TO GROUND

C. L 3 TO L 2

22. THREE PHASE LINE VOLTAGE AND LINE DROP

NO LOAD LINE VOLTAGE VOLTS

A. PHASE A TO B

B. PHASE B TO C

C. PHASE A TO C

LINE DROP TEST VOLTS

D. L 1 TO L 2

23. TRANSFORMER BALANCE 1

A. ANODE VOLTAGE TO GROUND AT 100 KVP

B. CATHODE VOLTAGE TO GROUND AT 100 KVP

LINE DROP TEST VOLTS

D. PHASE A TO B

E. PHASE B TO C

F. PHASE A TO C

24. EXPOSURE TIMER TEST

TIME SETTING ON CONTROL

ACTUAL TIME MEASURED

1 Only required annually.

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PREVIOUS EDITION IS OBSOLETE.

DD FORM 2164 Reverse, NOV 78

25. KILOVOLTAGE AND MILLIAMPERAGE VERIFICATION

CONTROL

SETTINGS

KILOVOLTAGE

20 40 60 80 100 120 140 150

MA

MA

MA

MA

MA

MA

MA

MA

26. PENETROMETER FILM DENSITY SATISFACTORY UNSATISFACTORY

27. RADIOGRAPHIC PHOTOTIMER TEST (Record MAS)

BUCKY CHEST OTHER

A. NORMAL

B. LIGHT

C. DARK

V. FLUOROSCOPIC CERTIFICATION

28. KILOVOLTAGE VERIFICATION

MA

SETTING

KILOVOLTAGE PEAK

FLUORO ACTUAL

1.0 40

1.0 60

1.0 80

1.0 100

1.0 120

1.0 MAXIMUM

29. AUTOMATIC BRIGHTNESS CONTROL

SATISFACTORY

UNSATISFACTORY

30. SPOT FILM KILOVOLTAGE VERIFICATION

KILOVOLTAGE PEAK

SPOT FILM SETTING ACTUAL

60 @

80 @

100 @

120 @

MA

MA

MA

MA

31. SPOT FILM MILLIAMPERAGE AND SPACE CHARGE VERIFICATION

FIXED MA

STATION

ACTUAL MILLIAMPERAGE AT

LOW KVP NEUTRAL KVP HIGH KVP

32. FLUOROSCOPIC MILLIAMPERAGE VERIFICATION

MA

STATION

NEUTRAL KVP

SETTING

ACTUAL

MA

33. FLUORO TIMER TEST (Timer set at 5 minutes)

A. WARNING DEVICE ALARMED AT MINUTES

B. TIMER TERMINATED AT MIN SEC

C. DID TIMER TERMINATE EXPOSURE?

YES NO

D. IS TIMER TIMING CORRECTLY WHEN CHECKED AGAINST

CALIBRATED STOP WATCH? YES NO

34. SPOT FILM TIMER TEST SATFY UNSATFY

A. SHORT TIME

B. MEDIUM TIME

C. LONG TIME

35. PHOTOTIMER TEST RECORD MAS

A. NORMAL SETTING

B. LIGHT SETTING (-)

C. DARK SETTING (+)

INSPECTED BY (Type or print name and grade) SIGNATURE

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