Perfexion to ICON Upgrade - Site Inspection / Verification Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Pre Delivery Site Info:

• Hospital Name:

• Hospital Address:
  Address
• Delivery Address if Different:
  Address

• Radiation Safety Officer info:

• RSO Name:

• RSO Contact #:

• Elekta is responsible for rigging if considered "Standard Rigging"

• Does Delivery area and rigging path meet Elekta Standard Rigging Parameters?

  Yes

  No

  N/A

• Description of non-standard rigging parameters:

• Pictures of rigging concerns:

  Media

• Has the rigging been arranged?

  Yes

  No

  N/A

• Name of rigging firm:

• Contact name & phone:

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

  Yes

  No

  N/A

• Agreed on the delivery of Upgrade items:

  Date

• Hospital's main contact info for deliveries:

• Elekta's Riggers contact info:

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

  Yes

  No

  N/A

• Schedule date of Acceptance:

  Date

• Customer Representative Signature:

  Sign

• Elekta Representative Signature:

  Sign

• Additional comments:

Equipment Delivery Information

• Description of offloading / staging area:

• Pictures of offloading / rigging area:

  Media

• Has it been determined that the minimum dimensions of 40"w 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 the delivery route?

  Yes

  No

  N/A

• Description of rigging path including door sizes:

• Pictures of rigging path:

  Media

• 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

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

  Yes

  No

  N/A

• Additional comments:

Treatment Room Inspection

• 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.

• 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 3 phase voltage.

• Record the single phase voltage:

• Does the shunt trip button trip both breakers?

  Yes

  No

  N/A

• Is the new electrical floor box in the correct location with respect to RU isocenter per the Elekta Reference Drawings?

  Yes

  No

  N/A

• Have the 3 phase wires been installed with 8' tails pulled to the Floor box?

  Yes

  No

  N/A

• Has the electrician installed signals wires from helper relay to floor box with 6' pigtails?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• (CAM1) Is there enough cable to move camera max 18" horizontal from isocenter if needed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Additional comments:

Control Area Inspection:

• Is there enough room on control counter for an additional workstation?

  Yes

  No

  N/A

• Are the 120vac power outlets open for additional workstation monitor?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are the final lighting and controls installed and operational?

  Yes

  No

  N/A

• Are the additional 2 hospital network drops installed and operational?

  Yes

  No

  N/A

• If not, when will they be installed?

  Date

• When will they be operational?

  Date

• Has Network information been provided by hospital & forwarded to Project Manager?

  Yes

  No

  N/A

• Is there a working telephone in the control area?

  Yes

  No

  N/A

• What is the phone number:

• Additional Comments: