BERITA ACARA UJI FUNGSI

Pada hari ini …………………….……. tanggal ……………..…….……… bulan …………………….…..

tahun …………………………………………………., telah dilaksanakan Uji Fungsi Mesin sesuai
dengan E-Catalog No. AKS-P2006-3000424 tanggal 26 Juni 2020 untuk mesin dibawah ini:

No Product Name Qty

42295124-AKS-004727368
1 RAPIDVAC™ Smoke Evacuator COVIDIEN, 1 PC
CVPLP2000 -Valleylab™ Smoke Evacuation Pencil
42295143-AKS-004727355
2 FORCE TRIAD™ Energy Platform and Accessories 1 PC
COVIDIEN, E0017 - UNIV ACTIVE ADPT
42295143-AKS-004727331
3 FORCE TRIAD™ Energy Platform and Accessories 5 PC
COVIDIEN, E0020V - Foot Switching Bipolar Cord
42295143-AKS-004727335
VALLEYLAB Electrosurgical Return Electrodes
4 250 PC
COVIDIEN, E7507-Valleylab™ REM Polyhesive™
Adult Patient Return Electrode 9' (2.7m)
42295143-AKS-004727338
VALLEYLAB Electrosurgical Return Electrodes
5 100 PC
COVIDIEN, E7512 - Valleylab™ REM Polyhesive™
Neonatal Patient Return Electrode 9' (2.7m)
42295124-AKS-004727372
RAPIDVAC™ Smoke Evacuator COVIDIEN,
6 20 PC
SEA3720 - RapidVac™ Smoke Lap Tubing Kit with
Valve 1/4
42295124-AKS-004727367
7 RAPIDVAC™ Smoke Evacuator COVIDIEN, 3 PC
SEA3745 - RapidVac™ Footswitch
42295124-AKS-004727365
8 RAPIDVAC™ Smoke Evacuator COVIDIEN, SE3695 1 UNIT
RAPIDVAC™ Smoke Evacuator

OFFICE : POSTAL ADDRESS : TELEPHONE : FACSIMILE : E – MAIL :

Jln. P. Jayakarta 24 / 34-35 P.O.Box 4773 021 - 6493880 021 - 6298649 service@intergastra.co.id
Jakarta – 10730 Jakarta 10001 021 - 6397402
Indonesia 021 - 6397096
 42295143-AKS-004727330

9 10 PC
EDGE Electrosurgical Pencils COVIDIEN, E2100Valleylab™ Rocker
Switch Pencil Reusable 15'(4.6m)
42295124-AKS-004727371
10 RAPIDVAC™ Smoke Evacuator COVIDIEN, 5 PC
SEA3730 - RapidVac™ Interlink Cable
42295143-AKS-004727337
VALLEYLAB Electrosurgical Return Electrodes
11 150 PC
COVIDIEN, E7510-25 -Valleylab™ REM
Polyhesive™ Infant Patient Return Electrode 9' (2.7m)
42295143-AKS-004727339
12 FORCE TRIAD™ Energy Platform and Accessories 200 PC
COVIDIEN, E2401 - LECTROBRASIVE
42295124-AKS-004727364
13 RAPIDVAC™ Smoke Evacuator COVIDIEN, 3 PC
CVPLP2000 - Valleylab™ Smoke Evacuation Pencil
42295143-AKS-004728119
14 WEM Microprocessed Electrosurgical Unit Model 1 PC
SS-501SX WEM, 06523 - FS-16 Double Footswitch
42295143-AKS-004728122
15 WEM Microprocessed Electrosurgical Unit Model 1 UNIT
SS-501SX WEM, 04718 - TU-27 Transport Unit
42295104-AKS-004728117
WEM Microprocessed Electrosurgical Unit Model
16 1 UNIT
SS-501SX WEM, 06725 - SS-501SX
Microprocessed Electrosurgical Unit
42295143-AKS-004703626
17 5 PC
VALLEYLAB™ Bayonet Forceps

Dimana mesin tersebut sudah dapat berfungsi dengan baik.

Demikianlah Berita Acara Uji Fungsi ini kami buat untuk dapat dipergunakan
sebagaimana mestinya.

PT. INTERGASTRA NUSANTARA RSUD Dr. M. Zein Painan

( ) ( )
 BERITA ACARA TRAINING

Pada hari ini …………………….……. tanggal ……………..…….……… bulan …………………….…..

tahun …………………………………………………., telah dilaksanakan Training/Uji Fungsi sesuai
dengan E-Catalog No. AKS-P2006-3000424 tanggal 26 Juni 2020 untuk mesin dibawah ini:

No Product Name Qty

42295124-AKS-004727368
1 RAPIDVAC™ Smoke Evacuator COVIDIEN, 1 PC
CVPLP2000 -Valleylab™ Smoke Evacuation Pencil
42295143-AKS-004727355
2 FORCE TRIAD™ Energy Platform and Accessories 1 PC
COVIDIEN, E0017 - UNIV ACTIVE ADPT
42295143-AKS-004727331
3 FORCE TRIAD™ Energy Platform and Accessories 5 PC
COVIDIEN, E0020V - Foot Switching Bipolar Cord
42295143-AKS-004727335
VALLEYLAB Electrosurgical Return Electrodes
4 250 PC
COVIDIEN, E7507-Valleylab™ REM Polyhesive™
Adult Patient Return Electrode 9' (2.7m)
42295143-AKS-004727338
VALLEYLAB Electrosurgical Return Electrodes
5 100 PC
COVIDIEN, E7512 - Valleylab™ REM Polyhesive™
Neonatal Patient Return Electrode 9' (2.7m)
42295124-AKS-004727372
RAPIDVAC™ Smoke Evacuator COVIDIEN,
6 20 PC
SEA3720 - RapidVac™ Smoke Lap Tubing Kit with
Valve 1/4
42295124-AKS-004727367
7 RAPIDVAC™ Smoke Evacuator COVIDIEN, 3 PC
SEA3745 - RapidVac™ Footswitch
42295124-AKS-004727365
8 RAPIDVAC™ Smoke Evacuator COVIDIEN, SE3695 1 UNIT
RAPIDVAC™ Smoke Evacuator

OFFICE : POSTAL ADDRESS : TELEPHONE : FACSIMILE : E – MAIL :

Jln. P. Jayakarta 24 / 34-35 P.O.Box 4773 021 - 6493880 021 - 6298649 service@intergastra.co.id
Jakarta – 10730 Jakarta 10001 021 - 6397402
Indonesia 021 - 6397096

42295143-AKS-004727330

9 10 PC
EDGE Electrosurgical Pencils COVIDIEN, E2100Valleylab™ Rocker
Switch Pencil Reusable 15'(4.6m)
42295124-AKS-004727371
10 RAPIDVAC™ Smoke Evacuator COVIDIEN, 5 PC
SEA3730 - RapidVac™ Interlink Cable
42295143-AKS-004727337
VALLEYLAB Electrosurgical Return Electrodes
11 150 PC
COVIDIEN, E7510-25 -Valleylab™ REM
Polyhesive™ Infant Patient Return Electrode 9' (2.7m)
42295143-AKS-004727339
12 FORCE TRIAD™ Energy Platform and Accessories 200 PC
COVIDIEN, E2401 - LECTROBRASIVE
42295124-AKS-004727364
13 RAPIDVAC™ Smoke Evacuator COVIDIEN, 3 PC
CVPLP2000 - Valleylab™ Smoke Evacuation Pencil
42295143-AKS-004728119
14 WEM Microprocessed Electrosurgical Unit Model 1 PC
SS-501SX WEM, 06523 - FS-16 Double Footswitch
42295143-AKS-004728122
15 WEM Microprocessed Electrosurgical Unit Model 1 UNIT
SS-501SX WEM, 04718 - TU-27 Transport Unit
42295104-AKS-004728117
WEM Microprocessed Electrosurgical Unit Model
16 1 UNIT
SS-501SX WEM, 06725 - SS-501SX
Microprocessed Electrosurgical Unit
42295143-AKS-004703626
17 5 PC
VALLEYLAB™ Bayonet Forceps

Berikut nama-nama yang mengikuti Training Mesin :

NAMA TANDA TANGAN

1. ……………………………………….. ……………………………….

2. ……………………………………….. ……………………………….

3. ………………………………………. ……………………………….

4. ……………………………………….. ……………………………….

5. ……………………………………….. ……………………………….
6. ……………………………………….. ……………………………….

7. ……………………………………….. ……………………………….

8. ……………………………………….. ………………………………

9. …………………………………….. ……………………………….

10.……………………………………….. ……………………………….

Demikianlah Berita Acara Training kami buat untuk dapat dipergunakan sebagaimana
mestinya.

PT. INTERGASTRA NUSANTARA RSUD Dr. M. Zein Painan

( ) ( )
 BERITA ACARA SERAH TERIMA BARANG

Pada hari ini …………………….……. tanggal ……………..…….……… bulan …………………….…..

tahun …………………………………………………., telah dilaksanakan Serah Terima Barang
sesuai dengan E-Catalog No. AKS-P2006-3000424 tanggal 26 Juni 2020 untuk mesin
dibawah ini:

No Product Name Qty

42295124-AKS-004727368
1 RAPIDVAC™ Smoke Evacuator COVIDIEN, 1 PC
CVPLP2000 -Valleylab™ Smoke Evacuation Pencil
42295143-AKS-004727355
2 FORCE TRIAD™ Energy Platform and Accessories 1 PC
COVIDIEN, E0017 - UNIV ACTIVE ADPT
42295143-AKS-004727331
3 FORCE TRIAD™ Energy Platform and Accessories 5 PC
COVIDIEN, E0020V - Foot Switching Bipolar Cord
42295143-AKS-004727335
VALLEYLAB Electrosurgical Return Electrodes
4 250 PC
COVIDIEN, E7507-Valleylab™ REM Polyhesive™
Adult Patient Return Electrode 9' (2.7m)
42295143-AKS-004727338
VALLEYLAB Electrosurgical Return Electrodes
5 100 PC
COVIDIEN, E7512 - Valleylab™ REM Polyhesive™
Neonatal Patient Return Electrode 9' (2.7m)
42295124-AKS-004727372
RAPIDVAC™ Smoke Evacuator COVIDIEN,
6 20 PC
SEA3720 - RapidVac™ Smoke Lap Tubing Kit with
Valve 1/4
42295124-AKS-004727367
7 RAPIDVAC™ Smoke Evacuator COVIDIEN, 3 PC
SEA3745 - RapidVac™ Footswitch
42295124-AKS-004727365
8 RAPIDVAC™ Smoke Evacuator COVIDIEN, SE3695 1 UNIT
RAPIDVAC™ Smoke Evacuator

OFFICE : POSTAL ADDRESS : TELEPHONE : FACSIMILE : E – MAIL :

Jln. P. Jayakarta 24 / 34-35 P.O.Box 4773 021 - 6493880 021 - 6298649 service@intergastra.co.id
Jakarta – 10730 Jakarta 10001 021 - 6397402
Indonesia 021 - 6397096
42295143-AKS-004727330

9 10 PC
EDGE Electrosurgical Pencils COVIDIEN, E2100Valleylab™ Rocker
Switch Pencil Reusable 15'(4.6m)
42295124-AKS-004727371
10 RAPIDVAC™ Smoke Evacuator COVIDIEN, 5 PC
SEA3730 - RapidVac™ Interlink Cable
42295143-AKS-004727337
VALLEYLAB Electrosurgical Return Electrodes
11 150 PC
COVIDIEN, E7510-25 -Valleylab™ REM
Polyhesive™ Infant Patient Return Electrode 9' (2.7m)
42295143-AKS-004727339
12 FORCE TRIAD™ Energy Platform and Accessories 200 PC
COVIDIEN, E2401 - LECTROBRASIVE
42295124-AKS-004727364
13 RAPIDVAC™ Smoke Evacuator COVIDIEN, 3 PC
CVPLP2000 - Valleylab™ Smoke Evacuation Pencil
42295143-AKS-004728119
14 WEM Microprocessed Electrosurgical Unit Model 1 PC
SS-501SX WEM, 06523 - FS-16 Double Footswitch
42295143-AKS-004728122
15 WEM Microprocessed Electrosurgical Unit Model 1 UNIT
SS-501SX WEM, 04718 - TU-27 Transport Unit
42295104-AKS-004728117
WEM Microprocessed Electrosurgical Unit Model
16 1 UNIT
SS-501SX WEM, 06725 - SS-501SX
Microprocessed Electrosurgical Unit
42295143-AKS-004703626
17 5 PC
VALLEYLAB™ Bayonet Forceps

Dimana mesin tersebut sudah dapat berfungsi dengan baik.

Demikianlah Berita Acara Serah Terima Barang ini kami buat untuk dapat dipergunakan
sebagaimana mestinya.

PT. INTERGASTRA NUSANTARA RSUD Dr. M. Zein Painan

( ) ( )