Arkray Assure PRISM MULTI - Field Inspection Report

SECTION
F
36
Field Inspection Report Assure
®
Prism multi Blood Glucose Monitoring System
Facility: _________________________________ Date: ___________________________ Contact: ______________________________ Address: ________________________________ Time: ___________________________ Phone: ________________________________ _________________________________ ARKRAY Representative Signature: __________________________________________ Comments: __________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _________________________________________
Name of facility:
________________________________
Minneapolis, MN 55439 USA TEL 800.818.8877 FAX 952.646.3110 www.arkrayusa.com
Station Meter Serial #
Control 1 – Control Solution Control 2 – Control Solution
Time and Date Correct
Meter Replaced
Replacement Meter Serial #
Range Result Range Result (Y/N) (Y/N)