Leksell Gamma Knife Site Inspection Report - Perfexion / ICON

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Site specification

• Hospital Name:

• Hospital Address:
  Address

• Date of inspection:

  Date

• Reason for inspection:

• Customer Representative Signature:

  Sign

• Elekta Representative Signature:

  Sign

Pre-Installation Administration

• Have all parties agreed on the delivery and loading date for the unit?

  Yes

  No

  N/A

• What is the date?

  Date

• Has the rigging firm been hired and reviewed the delivery route?

  Yes

  No

  N/A

• Contact name & phone:

• Name of rigging firm:

• Have the owner and rigging firm discussed and agreed on the space needed for staging of equipment during deliveries?

  Yes

  No

  N/A

• Will a lockable area be available for the storage of delivered equipment and tools?

  Yes

  No

  N/A

• Has the radioactive materials license been received by the user and a copy sent to Elekta Project Manager?

  Yes

  No

  N/A

• What type of license is on hand?

  possession

  use

  both

• Is the Radiation Safety Officer, or Authorized person, available to receive the radioactive material on the selected date as per the license conditions?

  Yes

  No

  N/A

• RSO Name:

• RSO Contact #:

• Have the Scanner Interface Forms and Adapter Information been complete and returned to Elekta Project Manager?

  Yes

  No

  N/A

• If project is an upgrade to Perfexion, has the "Back to Factory" kit been ordered?

  Yes

  No

  N/A

• Additional comments:

Access to site / offloading area

• Has the rigger reviewed the area designated for delivery and will that area be clean and unoccupied at delivery time?

  Yes

  No

  N/A

• Is the off loading area flat and at the same height as the entrance to the hospital building?

  Yes

  No

  N/A

• If not, who is responsible for preparing the equipment landing area for the off loading?

• Name:

• Contact number:

• Date this will be done:

  Date

• Has security been notified of the area needed, the timing and extent of the rigging operations of the equipment deliveries and pickup?

  Yes

  No

  N/A

• Has the radiation safety officer reviewed the delivery route for the cobalt, both outside and inside the building?

  Yes

  No

  N/A

• Has it been determined that the minimum dimensions of 72" x 80"h (clear opening) of the delivery route have been met?

  Yes

  No

  N/A

• If not, have arrangements been made to ensure that the minimum dimensions are met throughout th delivery route?

  Yes

  No

  N/A

• Has it been determined that the delivery route can support the 40,000 lbs of the radiation unit, rigging equipment and personnel necessary to move the unit?

  Yes

  No

  N/A

• Is there finished flooring in the delivery route and if so, has the rigger been advised and agreed on flooring protection that will be used?

  Yes

  No

  N/A

• NOTE: It is recommended that the finished flooring be in place in the loading are before the delivery of he radiation unit. ( except Terrazzo or Clay Tile)

• Has the delivery route for the reminder of the system components been determined and will it be clean and clear of obstructions on the delivery date?

  Yes

  No

  N/A

• i.e. patient couch, covers, electrical cabinets, etc

• Is there a gradient in he delivery route?

  yes

  no

• Has the rigger reviewed it and made arrangements for equipment necessary to affect delivery?

  Yes

  No

  N/A

• Has security been informed and have a plan in place if parking/blocking roadways are involved?

  Yes

  No

  N/A

• NOTE: On new construction sites the entire delivery route must be clean and clear of all obstructions the day before delivery.

• NOTE: On existing building sites, hospital personnel must be clear of the delivery route during equipment movements and any obstructions must be removed.

• Additional comments:

Treatment Room

• Has the ECU floor box for the radiation unit been checked for correct position?

  Yes

  No

  N/A

• Has all new concrete work been complete?

  Yes

  No

  N/A

• Has the floor been checked for levelness spec of 1/8" in 10'?

  Yes

  No

  N/A

• Have the door(s) been hung and checked operational with locks to secure the radioactive material once it is on site?

  Yes

  No

  N/A

• Who will have the keys for access?

• Contact number?

• Are the final lighting and controls installed and operational?

  Yes

  No

  N/A

• Is HVAC system installed and operational with ducts cleaned to ensure controllable temperature = 50 - 80 deg & humidity = 30-75% (min/maxi) 24/7?

  Yes

  No

  N/A

• Elekta recommends 72-79 deg for patient comfort & 30-50% humidity for optimum equipment operation.

• Are the 120vac power outlets operational in the vault?

  Yes

  No

  N/A

• Is the ceiling height at 9'-6" (min) to allow loading to occur inside the treatment room?

  Yes

  No

  N/A

• Is the the site using the Nova Solutions Disconnect Panel?

  Yes

  No

  N/A

• Has a separate 3 phase and single phase disconnects been installed in the treatment room?

  Yes

  No

  N/A

• Has a 50amp contactor been installed with helper relay?

  Yes

  No

  N/A

• Record the voltage & current specs of the helper relay coil?

• Record the single phase voltage

• Record the 3 phase voltage:

• Does the shunt trip button trip both breakers?

  Yes

  No

  N/A

• Have all the Pause, Equipment Stop, and Door Switch wires pulled to floor box with 8' pigtails?

  Yes

  No

  N/A

• (PAS) Does the Pause Wall Switch operate correctly? (N.O. mom)

  Yes

  No

  N/A

• (ESS) Does the Equipment Stop wall switch operate correctly? (N.C. latching)

  Yes

  No

  N/A

• (DS1 / 2) Does the door switch/es operate correctly when treatment room doors close? (Doors closed = short)

  Yes

  No

  N/A

• (RON) Does the Radiation Warning Light operate when control wires are shorted together?

  Yes

  No

  N/A

• Record the Voltage and Current measured across RON control wires: (24vac, <1.0 amp)

• (TRM) Confirm there is an empty 1" & 2" conduit w/pull strings from Treatment Room Monitor location to control room.

  Yes

  No

  N/A

• (USI) Confirm there is an empty 2" conduit w/ pull string from User Status Indicator location to Floor box under RU.

  Yes

  No

  N/A

• (CAM1) Confirm there is an empty 2" conduit w/ pull string from Camera location on isocenter to control room.

  Yes

  No

  N/A

• (CAM2) Confirm an empty conduit has been run from 2nd customer supplied and customer installed camera location to control room.

  Yes

  No

  N/A

• (RM) Confirm a conduit path and outlets at both ends for a customer supplied and customer installed Radiation Monitoring Device.

  Yes

  No

  N/A

• Are all electrical box covers mounted and all conduits labelled as to destination?

  Yes

  No

  N/A

• Are the pull strings been installed in the conduits for Elekta installed cables?

  Yes

  No

  N/A

• If in-line pull boxes have been installed, the electrical contractor needs to have personnel standing by to assist in the pulling of the Elekta supplied cables.

• Has the contractor been advised if applicable?

  Yes

  No

  N/A

• Contractor name:

• Contact number:

• Is all the work completed in the treatment room, control room, and planning room to allow installation to take place without interruption?

  Yes

  No

  N/A

• This includes all flooring, ceiling work, cabinetry, conduits, contractor wiring, user supplied cameras, door switches, e-stops, in-room radiation monitor, data link cabling, and phone lines, etc.

• Has the installation been discussed with the site physicist and is he/she available for acceptance testing as needed?

  Yes

  No

  N/A

• Have final floor finishes (except Terrazzo & Clay tile) been installed?

  Yes

  No

  N/A

• Have all Pause, Emergency, Stop, and Door Switches been installed with 8' tails pulled to the ECU box?

  Yes

  No

  N/A

• Additional comments:

Control Area

• Is all millwork installed and cable passages drilled in counter tops with grommets installed?

  Yes

  No

  N/A

• NOTE: the cable passages can be drilled while the installers are on site to determine best location if the contractor will be on site during the installation.

• Are the conduits and cable ducts installed?

  Yes

  No

  N/A

• NOTE: all conduits and cable ducts must be grounded.

• Are the conduits and cable ducts clean and clear?

  Yes

  No

  N/A

• Do he cable duct covers fit correctly?

  Yes

  No

  N/A

• Are pull strings installed in the conduits that will be used for Elekta supplied cables?

  Yes

  No

  N/A

• Are the 120vac power outlets operational and in the control room?

  Yes

  No

  N/A

• Are the final floor finishes installed?

  Yes

  No

  N/A

• If not, when will this be done?

  Date

• Are the ceiling grid and all ceiling tiles installed?

  Yes

  No

  N/A

• Is the control room dust free and cleared of debris?

  Yes

  No

  N/A

• Is HVAC system installed and operational with ducts cleaned to ensure controllable temperature = 50 - 80 deg & humidity = 30-75% (min/maxi) 24/7?

  Yes

  No

  N/A

• Elekta recommends 72-79 deg for patient comfort & 30-50% humidity for optimum equipment operation.

• Are the final lighting and controls installed and operational?

  Yes

  No

  N/A

• Are the hospital network drops installed and operational? (2 minimum)

  Yes

  No

  N/A

• If not, when will they be installed?

  Date

• When will they be operational?

  Date

• Is there a working telephone in the control area?

  Yes

  No

  N/A

• What is the phone number:

• Additional Comments:

Treatment Planning Area

• Is all millwork installed and cable passages drilled in counter tops with grommets installed?

  Yes

  No

  N/A

• NOTE: the cable passages can be drilled while the installers are on site to determine best location if the contractor will be on site during the installation.

• Are the hospital network drops installed and operational?

  Yes

  No

  N/A

• If not, when will they be installed?

  Date

• When will they be operational?

  Date

• Are the 120vac power outlets operational and in the control room?

  Yes

  No

  N/A

• Are the door(s) installed and lockable?

  Yes

  No

  N/A

• Who will have the keys for access?

• Are the final floor finishes installed?

  Yes

  No

  N/A

• Are the ceiling grid and all ceiling tiles installed?

  Yes

  No

  N/A

• Is HVAC system installed and operational with ducts cleaned to ensure controllable temperature = 50 - 80 deg & humidity = 30-75% (min/maxi) 24/7?

  Yes

  No

  N/A

• Elekta recommends 72-79 deg for patient comfort & 30-50% humidity for optimum equipment operation.

• Are the final lighting and controls installed and operational?

  Yes

  No

  N/A

• Is there a working telephone in the control area?

  Yes

  No

  N/A

• What is the phone number?

• Additional Comments: