Doc: No. MiG-FOR-TSS.03-001-02 FORM Effective Date; 28 JUL 2020 EXee Revision No. : 02 SERVICE REPORT Page Ma ae ai Barat of Seni Report Reco: 10010 [IMI Customer Name —:BSUP_ FAT ewan Calls Statistics Labor (ime) : ©] Hours. Address SRG Fanprrs, Woy CilArgne __—‘Travel(time) : Hours Travel (days) : A) Days Merta _ skeawin as ‘TSS arrival on site Contact Person :_ [Bu Dona Date US mde 20th Time tooo. Phone No. OVE by SSSI ae Instrument returned for service System ox Date TE Mde tor Time tee. Serial No. Fem. ta cerca AT Type of Service* —_: [1] Installation [i Repair 1 otter... V4. Preventive Maintenance [1] Customer Visit Customer Reported INSTAL _UfS Work Have Been Done fut %« old Pow pe Cager Race ith New Cage © 2 ves 4 1k TM TEST _furcee ON IN S7pu re = Lee + Cotecy (%\ Repny © UATR Remark _ Acar Mr Digvtmta 1 Description Quantity | _ Price! Unit wa N/i |Medquest's Technical Support Service |Customer_ Printed Name ; (2>) ___ [Printed Name : Novi Yandane Signature :__ (SB - Date: 2 cde tet |Sionatue: sa NO rata AC Me tor *) Give a mark (1) in appropriate square PY Medquost Jaya Global STALAST Menara Salemba 6th Fl Zone 1, JI. Salemba Raya No. §- SA, Jakarta Pusat 10440 ° Indonesia Toip | +6221 3084 2061, Fax: +6221 3103 7735734582_RSUP FATMAWATIJAKARTA, 25/08/21 10:46:30 SELATAN_INDONESIA GeneXpert® Dx System Installation Qualification Report This report provides documented evidence of the installation of this GeneXpert® Dx Systen. System Information GeneXpert® Dx System 1 Java Runtime Environment 1,8,0_131 Pass GX Utils. OLL 0.8.4.0 Pass SQL Database Microsoft SQL Server 13.00.4001 Pass Database ox.db 3.0.9.0 Pass Operating System Windows 10 10.0 Pass CIT Plugin 1 Pass Instrument information Instrument A At 862106 24.3 Pass. a2 862107 23.0 Pass 3 862109 24.7 Pass AA 862108 3. 24.2 Pass Shaded Modules = Reporter is out of calibration, GeneXpert® Dx System Version 5.1 Page‘ of 3‘734582_RSUP FATMAWATI_JAKARTA 25/03/21 10:46:30 ‘SELATAN_INDONESIA GeneXpert® Dx System d Installation Qualification Report Instrument B [etc 5 734583, (eetenen Te rT Status a 862102, 3.3.3 20.9 Pass 82 862104 3.3.3 213 Pass 83 862105, 333 22 Pass Ba 862103 3.3.3 22.4 Pass Shaded Modules = Reporter is out of calibration. Instrument C Instrumer 734584 (eemeency Modu! C1 962098 33.3 247 Pass. c2 862097 33.3 22.4 Pass 3 862104 3.33 21.8 Pass ca 962092 33.3 21.9 Pass ‘Shaded Modules = Reporter is out of calibration. Instrument D (eaten Dt 862180 . 24.7 Pass 2 862114 22.5 Pass D3 862115, 21.6 Pass Da 862169, . 214 Pass Shaded Modules = Reporter is out of calibration. jeneXpert® Dx System Version 5.1 Page 2 of 3734562_RSUP FATMAWATI_JAKARTA 25/03/21 10:52:38 SELATAN_INDONESIA GeneXpert® Dx System Installation Qualification Report Available Assays Xpert MTB-RIF Assay G4 6 In Vitro Diagnostic Xpert Xpress SARS-CoV-2 2 In Vitro Diagnostic Installation of networked instruments complies with the setup requirements specified in the GeneXpert® Dx ‘System Operator Manual, ‘Installation’ section. Verified by Date This 1Q is acceptable if all System Information and Instrument Information are listed as ‘Pass’, All instrument modules that are listed as ‘Pass’ are available for use. Acceptance: [ ] Acceptable [ ] Not Acceptable Performed by Date Reviewed and approved by Date GeneXpert® Dx System Version 5.1 Page 3 of 8