11 COMPLIANCES
11.1 Statement of Compliance from Hospital/
Contractor
Compliance Form
STATEMENT OF COMPLIANCE FROM HOSPITAL/CONTRACTOR
___________________________________ (Hospital/Contractor Name)
(please print)
hereby confirms that (please mark the corresponding items with a “✓” as applicable):
☐ the electrical facility installation is operational and in compliance with applicable safety stand-
ards,
☐ an appropriate number of ropes, rope clips and rope tighteners for the ceiling mounts were
used.
and that all of the following ceiling mounted equipment is installed according to the respective
local regulations and Brainlab pre-installation parameters as described in the ExacT
rac Site
Planning Manual:
☐
ceiling mount of the IR camera (n/a for Varian T
rueBeam
TM
systems)
☐ ceiling mounts of the flat panel detectors
☐ upper part of the ceiling mounted monitor arm
☐ control room distribution box
☐ in-room distribution box
If any non-compliance exists, the hospital takes full responsibility for any possible related future
incidents.
___________________________________ ___________________________________
Hospital Representative/Contractor Date
Name
___________________________________ ___________________________________
Hospital Representative/Contractor Hospital Representative/Contractor
Stamp Signature
COMPLIANCES
Site Planning Manual Rev. 1.0 ExacTrac Ver. 6.x 95
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