Hospital: . Sirius SN: .

Customer
Print Name: .
Address: . Front Panel SW: . Signature: .
........ Date: .
City: . ST: . Bav Controler SW: .
....... Representative
Contact: .. Model #: . Print Name: .
Signature: .
Phone Number: . Absorber SN: . Date: .
Visual Inspection High Pressure Outlets (= or > 80LPM) Ventilator
Description Pass Fail N/A Description Pass Fail N/A Description Pass Fail N/A
Cylinder Yokes O2 shaeder (if fitted) Compliance test
Pipeline Inlets O2 diss (if fitted) Systems check
Pipeline Hoses Air shraeder (if fitted) CALBK: flow control cal
Absorber Rods Hypoxic Guard/Flow Control Accuracy CALBK: inspiratory valve cal
Hp Outlet (if fitted) Description Pass Fail N/A CALBK: block and pressure zeros
Backbar Flowmeter backlight (non-EFM) Touchscreen calibration
O2 Flush Assy Min. O2 flow (130 - 170ml) Fresh gas calibration
Common Gas Outlet N2O = 1LPM (O2 = 21 - 30 %) VTI = 250 ±25ML
Flowmeter Assy / Control Knobs N2O = 6LPM (O2 = 21 - 30 %) VTI = 500 ±50ML
Drawers N2O = 12LPM (O2 = 21 - 35 %) VTI = 750 ±75ML
Castors O2 = 3LPM (O2 = 21 - 30 %) PEEP = 10 ±1.5cmH2O
Pipeline Leak Test O2 = 1.5LPM (O2 = 21 - 30 %) Pressure = 10 ±2cmH2O
Description Pass Fail N/A O2 = 0.4LPM (O2 = 21 - 30 %) Pressure = 30 ±3cmH2O
O2 O2 & N2O = 3LPM (O2 = 47 - 53 %) Pressure High Alarm
N2O (if fitted) O2 & N2O = 6LPM (O2 = 47 - 53 %) Alarms
Air (if fitted) O2 & Air = 3LPM (O2 = 57 - 63 %) Description Pass Fail N/A
Cylinder Leak Test O2 & Air = 6LPM (O2 = 57 - 63 %) Apnea
Description Pass Fail N/A Backbar Sustained pressure
O2 (if fitted) Description Pass Fail N/A Low gas pressure
2nd O2 (if fitted) Build up (150mmHg in 7 sec) Pressure low
N2O (if fitted) T1 (left side) O2 supply fail
2nd N2O (if fitted) T1 (right side) Pressure Limit
Air (if fitted) T2 (left side) Minute vol. Low
Cylinder Output Test (45 ± 2PSI) T2 (right side) Minute vol. High
Description Pass Fail N/A Common Gas Outlet Oxygen low
O2 (if fitted) Description Pass Fail N/A Oxygen high
2nd O2 (if fitted) O2 flush (35 - 55LPM) O2 sensor error
N2O (if fitted) PRV (3.25 - 3.95PSI) Mains fail
2nd N2O (if fitted) Suction Absorber not fitted
Air (if fitted) Description Pass Fail N/A Vaporizer Concentration (if fitted)
On/Off Switch Gas Cut Off Off position Description Pass Fail N/A
Description Pass Fail N/A Full position Vap s/n:
Switch "Off" no flow availibe Reg position Vap s/n:
Switch "On" flow availibe Absorber Vap s/n:
Switch "Off" flow drops to "0" Description Pass Fail N/A Vap s/n:
Switch "On" flow restored Expiratory leak test (<60ml/min) Vap s/n:
Oxygen Supply Failure Inspiratory leak test (<60ml/min) Electrical Safety
Description Pass Fail N/A APL = 65 (59 - 71cmH2O) Description Pass Fail N/A
Alarm sounds for 8 sec APL = 30 (24 - 36cmH2O) < 300µA(120/100 Vac)/< 500µA(220/240 Vac)
N2O drops to "0" (if fitted) APL = MIN (<5cmH2O) <0.2Ω
Air available (if fitted) BleaseSirius Service Checkout, PN 073-0301-00, Rev. B