Attachment 1d_ SOW Attachment 3 DD2164.pdf

DoD Form PDF 131 KB Posted May 13, 2024

Attached to: Combined Synopsis /Solicitation for Medical Lab Equipment Preventative Maintenance
Solicitation number: HU000124Q0012
Issued by: DOD Uniformed Services University of the Health Sciences

About this file

Written by GovTribe AI · May 13, 2024

This document is a DD Form 2164, which is an X-Ray Verification/Certification Worksheet used to inspect and test medical x-ray equipment. The form covers visual inspection of equipment components, operational testing of equipment features like interlocks and beam limiting devices, radiographic certification testing of line voltage, kilovoltage, milliamperage, and phototimer, as well as fluoroscopic certification testing of kilovoltage, brightness control, milliamperage, and timer. The form includes spaces to record the required actions, location, dates, and the inspector's name and signature.

The related federal contract opportunity is a combined synopsis/solicitation for preventative maintenance services on medical lab equipment, issued by the DOD Uniformed Services University of the Health Sciences. This is a small business set-aside solicitation seeking commercial services in accordance with FAR Parts 12 and 13. Refer to the attached Statement of Work for the full details of the requirement.

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Other versions and copies of DD Form 2164

2 government files on GovTribe name DD Form 2164. Different revisions are separate documents; copies of this exact file point search engines to its first posting.

File	Revision	Posted	Attached to
DD_Form_2164_and_2163__for_Appendix.pdf	Revision not stated	Feb 7, 2013	Preventive Maintenance & On-call Repair Services of Radiographic X-Ray Unit

Who attaches DD Form 2164

Agency	Files
Department of the Air Force Pacific Air Forces	1
DOD Uniformed Services University of the Health Sciences	1

Other files

File	Type	Posted
Questions and Answers_Medical Lab Equipment Maintenance_P0001.pdf	PDF	May 22, 2024
HU000124Q0012_0001.pdf	PDF	May 22, 2024
RFQ_Medical Lab Equipment Maintenance.pdf	PDF	May 13, 2024
Attachment 1c_ SOW Attachment 2 USUHS INST 4144 SIGNED.pdf	PDF	May 13, 2024
Attachment 1b_ SOW Attachment 1 Equipment List_BPA 2024APRR2.xlsx	XLSX spreadsheet	May 13, 2024
Attachment 2 BPA Ordering Instructions.pdf	PDF	May 13, 2024
Attachment 3 Provisions and Clauses_Medical Lab Equipment Maintenance BPA.pdf	PDF	May 13, 2024
Attachment 1a_ Statement of Work-Medical Equipment Maintenance_v.2.pdf	PDF	May 13, 2024

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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.

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

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

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 @

31. SPOT FILM MILLIAMPERAGE AND SPACE CHARGE VERIFICATION

FIXED MA

STATION

ACTUAL MILLIAMPERAGE AT

LOW KVP NEUTRAL KVP HIGH KVP

32. FLUOROSCOPIC MILLIAMPERAGE VERIFICATION

STATION

NEUTRAL KVP

SETTING

ACTUAL

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

DRAFT

SAMPLE

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2164, NOV 78

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2164 Reverse, NOV 78

X-RAY VERIFICATION/CERTIFICATION WORKSHEET

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

ACTION

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?

19. IS THE PRODUCTION OF X-RAYS INHIBITED UNTIL ANODE IS UP TO SPEED?

20. DOES BRAKE ON HIGH SPEED STATOR OPERATE CORRECTLY?

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.

25. KILOVOLTAGE AND MILLIAMPERAGE VERIFICATION

CONTROL SETTINGS

KILOVOLTAGE

26. PENETROMETER FILM DENSITY

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 1.0 1.0 1.0 1.0 1.0

MAXIMUM

29. AUTOMATIC BRIGHTNESS CONTROL

30. SPOT FILM KILOVOLTAGE VERIFICATION

KILOVOLTAGE PEAK

SPOT FILM SETTING

ACTUAL

60 @ 80 @ 100 @ 120 @

31. SPOT FILM MILLIAMPERAGE AND SPACE CHARGE VERIFICATION

FIXED MA STATION

ACTUAL MILLIAMPERAGE AT

32. FLUOROSCOPIC MILLIAMPERAGE VERIFICATION

MA STATION

NEUTRAL KVP SETTING

ACTUAL MA

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

MINUTES

SEC

C. DID TIMER TERMINATE EXPOSURE?

D. IS TIMER TIMING CORRECTLY WHEN CHECKED AGAINST

CALIBRATED STOP WATCH?

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 (+)

9.0.0.2.20120627.2.874785

Click this button to save this form.:

Click this button to print this form.:

Click this Reset button to erase data from all fields.:

ResetButton1:

Select if action is required.:

Select if action is not required.:

Select if action is taken.:

Enter location (include building and room number).:

Enter date and time of service.:

Enter date next service due.:

Radiographic certification. Exposure timer test. Enter actual time measured.:

Spot film timer test. Select if long time unsatisfactory.:

Enter coast down time for anode after exposure.:

Kilovoltage and Milliamperage verification. MA. Control setting 150. Enter kilovoltage.:

Phototimer test. Dark setting. Enter record MAS.:

Spot film milliamperage and space charge verification. Actual milliamperage. Enter low KVP.:

Spot film milliamperage and space charge verification. Actual milliamperage. Enter neutral KVP.:

Spot film milliamperage and space charge verification. Actual milliamperage. Enter high KVP.:

Fluoro timer test (timer set at 5 minutes). Enter minutes warning device alarmed at.:

Fluoro timer test (timer set at 5 minutes). Enter minutes timer terminated at.:

Fluoro timer test (timer set at 5 minutes). Enter seconds timer terminated at.:

Enter inspected by (type or print name and grade).:

Enter signature.:

File details come from the government source that posted it. Updated May 13, 2024.