PAGE 8-151118824, VER. 00
SYSTEM VERIFICATION DATA SHEET
Notification # (if applicable):
Model #/Serial #: /
Model Name:
Line Voltage:
Blower Hours
Pressure Verification Result (Circle one)
@ 4 cmH
2
0+ 1 cmH
2
0 PASS / FAIL
@ 20 cmH
2
0+ 2 cmH
2
0 PASS / FAIL
System Verification
Type Result (Circle one)
Trigger Performance PASS / FAIL
Ramp Performance PASS / FAIL
S Mode Trigger Performance PASS / FAIL
Alarm Verification
Alarm Type Result (Circle one)
Patient Disconnect PASS / FAIL
Apnea PASS / FAIL
Minute Ventilation PASS / FAIL
Loss of Input Power PASS / FAIL
Humidifier Test
Heater Plate warms when Heat setting is set to 1, 2, 3, 4, or 5 PASS / FAIL (circle one)
NOTE
If the device does not pass all tests, perform repairs as necessary and retest the device.
Tested By (Print / Sign): / Date: / /
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