Clear Form

OptiVantage Dual-Head Contrast Delivery System V-5 and Above

Test and Inspection Data

WARNING!

Service on any Injector must be performed by a Qualified Technician who is completely familiar
with its use and operation; trained by the manufacturer in the area of servicing the Injector; and
familiar with the content of the Operator’s and the Installation and Service manual.

Service Ticket Number

Call
Type N/A Service Work Performed Field Service Engineer Information
Preventive Maintenance Date
Installation Name
Repair Signature

Injector Information
Injector Component Serial Number Injector Component Software Version
Console Serial Number Console Software Version
Power-Head Serial Number Power-Head Software Version

POWER - SUPPLY UDI: PLEASE CHECKTHE APPROPRIATE BOX CORRESPONDINGTOTHE MODEL NUMBER AND FILL INTHE SERIAL NUMBER
844005 011074619000271021
844007 011074619000272721
_________________________
DE844005 011074619000401121
DS844005 011074619000402821 Power - Supply Serial Number

DL844005 011074619000403521
_________ ________________

Calibrated Controlled Test Equipment

Used N/A Test Equipment CCN# Calibration Due Date

Torque Wrench (in-lbs)

Pressure Gauge
Digital Volt Meter

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 Test and Inspection Data
The number preceding the heading corresponds to the test procedure
instructions located in the appropriate Service Manual 846083

4.2.2 POWER-SUPPLY CHECK 4.3.1 GROUND CONTINUTY

4.2.3 CONSOLE OPERATIONS

4.4 CEILING SUSPENSION SYSTEM

4.2.5 POWERHEAD OPERATIONS

NO SUSPENSION SYSTEM

4.2.6 REMOTE START OPERATIONS

OEM INTERFACE FEATURE INSTALLED

NO REMOTE START OEM Software Version ____________________

4.2.7 POWERHEAD STOP BUTTON NO OEM INTERFACE FEATURE INSTALLED

4.2.8 FACE PLATE DETECTION

4.2.9 RFID FACE PLATE DETECTION

NO RFID FACE-PLATE

Note: This section of Test and Inspection Data only needs to be completed If
one or more of the following conditions occur during the service event,
Select appropriate Check Box(s);

Installation Request Quality Regulatory Request Software Download

N/A Preventive Maintenance Extension Cables Replaced System Calibration

System Component Covers Removed Major Component Replacement

4.2.10 FLOW RATE CHECK 4.2.11 PRESSURE LIMIT CHECK

PROGRAMMED GAUGE READING @ PRESSURE LIMITING = (250 psi +/- 50 psi)

ACHIEVED ACHIEVED
PROGRAM RANGE  INJECTION 125 ml / RAM A 200 ml / RAM B
FACEPLATE VALUES A SIDE  VALUES B SIDE 
7.6 m/s @
275 PSI
10 ml/sec ± 0.2 ml/sec ml/ ml/
125ml sec sec
4.2.11 SI PRESSURE LIMIT CHECK
120 ml ± 2 ml
ml ml
Programmed Gauge Reading @ 175 psi (+/- 50 psi)
325 PSI < 300 PSI PSI PSI
Injection 125ml / Ram A and 200ml / Ram B

9.5ml/s @ 200psi
50 % contrast/saline

SI FEATURE NOT INSTALLED

NO ADDITIONAL SERVICE REQUIRED or CUSTOMER DECLINES SERVICE or

ASSOCIATED SERVICE TICKET _____________________

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