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)