101176 REV E 25
Functional Check
Inspection forms vary from hospital to hospital. The following sample form is intended as a guide so that the important
parameters are recorded.
T/Pump Functional Check and Safety Inspection Form
Date:_______________
Model Number:___________________ Serial Number:___________________
Item Value Okay Action
Needed?
Action
Taken
(check one)
1
Inspect physical condition (line cord, plug, housing)
Inspect hose connections and connectors
2
Measure flow, >7 gph (26.5 lph)...indicate value
3
Measure operating temperature @ 107ºF +2ºF
(42ºC+1ºC)...Indicate average
4
Backup limit test 110ºF - 120ºF (43.3ºC - 49ºC)
5
Leak Test
6
Measure ground resistance, <0.5 ohm...indicate value
7
Measure current leakage, <100µA (120 V), <200µA (230
V)
Signature:______________________________________________________________________
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