07-19-B1-729 FLO-GARD 6301 DUAL CHANNEL VOLUMETRIC INFUSION PUMP SERVICE MANUAL A-1
Appendix A
Operational Checkout Data Sheet Appendix A
This section contains a blank data sheet for recording the test results from the
Operational Checkout tests described in Chapter 10, “Operational Checkout”.
Reproduce one copy of the complete data sheet for each pump you test.
Pump Serial Number: _____________________________
Printed Name Signature Date
Tester: _____________________________ _____________________________ ____________
Reviewer (optional): _____________________________ _____________________________ ____________
Exterior Inspections
Exterior Inspection: Pump is clean and undamaged Fail R
Pass R
RTV Seal Check: RTV seal is present and evenly applied Fail R
Mounting Clamp Check
Mounting clamp moves freely
Fail R
Disc and cushion are installed correctly
Power cord is secure, undamaged, and is a Baxter-approved part Fail R
Software Check
Master Version Number:
Self Test
Pump 1
Power Up Self-Test completed successfully No R Yes R
Pump 2
Power Up Self-Test completed successfully No R Yes R
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