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Probe Return Check Sheet

Customer / Field Engineer: Please complete this form checking the area(s) of suspected failure or visible damage,
sign, date, and return one copy with your defective probe in the box provided, and one copy to Clinical
Engineering.

Probe model # ______________________________ Probe Serial #

___________________________________
A) Connector
1. Broken/Bent pins................................................
...............................................................................
2. Broken Locks.....................................................
3. Case Cracks........................................................
4. Fluid Intrusion....................................................
5. Broken wires.......................................................
B) Cable
1. Broken Wires in Sheath.....................................
2. Broken Strain Relief...........................................
3. Pulled Strain Relief............................................
4. Exposed Wires....................................................
5. Cuts / Damaged Sheath......................................
C) Cleaning
1. Improper / not recommended
Cleaning Fluids / Practices.................................
2. Improper Submergence Level............................
D) Head - Non Mechanical
1. Lens
A) Delamination........................................
B) Cuts.......................................................
C) Dents.....................................................
D) Holes.....................................................
E) Bite Marks............................................
2. Housing
A) Cracks...................................................
B) Cuts.......................................................
C) Dents.....................................................
D) Bite Marks............................................
3. Array
A) Poor Image Quality..............................
B) Broken Crystals - Image Lines............
A) Out of adjustment.................................
B) No Articulation....................................
C) Won’t lock or loose.............................
................................................................
2. Crystal Drive
A) Will not Drive...............................
B) Will not Calibrate.........................
3. Housing
A) Cracks...........................................
B) Cuts...............................................
C) Dents.............................................
4. Insertion Tube
A) Cuts...............................................
B) Dents.............................................
C) Holes.............................................
D) Bite Marks.....................................
E) Fluid Intrusion...............................
5. Bending Rubber
A) Cuts...............................................
B) Dents.............................................
C) Holes.............................................
D) Bite Marks.....................................
E) Epoxy Chip...................................
F) Crushed Linkage...........................
6. Tip
A) Cuts...............................................
B) Dents.............................................
C) Holes.............................................
D) Cracks...........................................
E) Bite Marks.....................................
F) Delaminating.................................
7. Thermister Failure................................................

2325229-100, Revision 0
E) Head - Mechanical
1. Membrane
A) Cuts…….……….…..…………….….
B) Dents.……….…….……....………….
C) Holes..….........
…………………….....
2. Housing
A) Cracks...................................................
B) Cuts.......................................................
C) Dents.....................................................

E) Head mechanical - Continued

3. Crystal
A) Poor Image Quality - Age....................
B) Crystal Broken / Missaligned...............
C) Crystal Drive Broken...........................

F) Transesophgeal Probes
1. Control Handle
2325229-100, Revision 0

5.Contract Exclusions

5.5. Any service, components or parts replacement, or downtime required as the result of (a) a design, specification, software
program, protocol, or instruction provided by you or your representative; (b) your failure to fulfill any of your obligations
or responsibilities under any Agreement; (c) the failure of anyone other than GE or its contractor to comply with GE's
written instructions or recommendations; (d) your combining the Equipment with any item of others or with any
incompatible GE item; (e) any alteration or improper storage, handling, use or maintenance of any part of the
Equipment by anyone other than GE or its contractor; (f) design or manufacturing defects, specifications, or
functionalities in any item of others; and (g) anything external to the Equipment, including building, van or trailer
structural deficiency, power surge, fluctuation or failure, or air conditioning failure.

Accidental probe damage protection for Ultrasound Products

The Accidental Probe Damage Replacement Feature provides replacement coverage during the term of the Agreement for
Equipment-related probe failures that occur as a result of normal operations, handling or storage, and accidental damage (for
example, cracking from high impact drops or cable rupture from rolling equipment over cable). The Accidental Probe Damage
Replacement program does not cover lost probes nor does it cover damage to probes caused by improper cleaning, disinfecting,
TEE bite marks, misuse or any other use that does not conform to the manufacturer guidelines. The maximum number of
replacement probes that will be provided during the annual coverage period is 2 per system under this Agreement. Claims must be
made by via GE’s standard service dispatch system. No claims that are reported after the agreement period will be covered under
the program, even if the damage occurred during the term of the Agreement. Replacement of TEE probes is limited to 50% of
exchange cost.

Customer Signature:________________________________ Field Engineer:____________________________________

Date: ________________ P.O.Number:_________________ Dispatch Number: ___________________