Upgrade LGK Site Inspection Report - PFX / ICON rev 2103

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Site specification

• Is this a LGK B/C to PFX/Icon

  Yes

  No

  N/A

• Old LGK Serial number?

• Scraping old system on site?

• Is this a LGK PFX to Icon

  Yes

  No

  N/A

• PFX serial number:

• Does the Clearance Check Tool have flex tip or not?<br>If not a CCT Calibration tool must be sent to site to be used during Phase 2 of the installation.

  Yes

  No

  N/A

• Is a reload

  Yes

  No

  N/A

• Hospital Name:

• Hospital Address:
  Address

• Date of inspection:

  Date

• Reason for inspection:

• Customer Representative Signature:

  Sign

• Local Elekta Representative Signature:

  Sign

• Elekta OF Sweden Signature

  Sign

Pre-Installation Administration

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

  Yes

  No

  N/A

• What is the delivery 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 #:

• Is network information available?<br>

  Yes

  No

  N/A

• IP address for the Router :

• Subnet mask:

• Default gateway address:

• Broadcast IP address:

• Domain name:

• DNS Server address:

• IP addresses to all known Dicom clients that are to send images to the LGK:

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

  Yes

  No

  N/A

FCO

• (N/A if the site does not have any Steriotaciall Vantage systems)

• YES if all old Vantage Fiducial Boxes AND MRI head coil adapters are replaced with latest versions, No in all other cases.

• Is FCO 100-06-301-001 implemented?

  Yes

  No

  N/A

• possession

  use

  both

• 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 2 meters width and 2 meter free hight (clear opening) of the delivery route have been met? No passage can be smaller then 1.9 m X 2.0 m.

  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

• Have pull points been installed (Hilti HKD-SR M20×80 or equivalent) in the rigging route and treatment room?

  Yes

  No

  N/A

• Has it been determined that the delivery route can support the 18500 KG of the radiation unit, rigging equipment and personnel necessary to move the unit, (floor<br>load requirement 20 tons / m²).

  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 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 the 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?

  Yes

  No

  N/A

• Does the area require earth quake kit

  Yes

  No

  N/A

• If earth quake kit is to be installed, has a contractor been contacted regarding the eight 32mm diameter and 180mm deep holes needed for bolts.

  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 = +22 to +26 °C (+15 °C to +30 °C during rigging) & humidity = less then 50% (30–75% during rigging) 24/7?

  Yes

  No

  N/A

• Elekta specify +22 to 26 °C for patient comfort & humidity less then 50% for optimum equipment operation.

• Is the ceiling height at 2600 mm (min) to allow loading to occur inside the treatment room?

  Yes

  No

  N/A

• Are the power outlets operational in the vault?

  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?

  Yes

  No

  N/A

• Has a R2 contactor been installed with helper relay (R1) and wiring to ECU floor box been installed?

  Yes

  No

  N/A

• Is R1 24VDC Relay?

  Yes

  No

  N/A

• Record the current at 24VDC or the resistance in the coil of R1

• Record the single phase voltage

• Record the 3 phase voltage:

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

  Yes

  No

  N/A

• Have all Pause, Emergency, Stop, and Door Switches installed prepared with 2.5 m tails pulled to the ECU box? <br>Door switch is not included on our delivery.

  Yes

  No

  N/A

• (ESS) Does the Emergency 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 25 mm & 50 mm conduit w/pull strings from Treatment Room Monitor location to control room.

  Yes

  No

  N/A

• (USI) Confirm there is an empty 50 mm conduit w/ pull string from User Status Indicator location to Floor box under RU.

  Yes

  No

  N/A

• (CAM1) Confirm there is an empty 50 mm conduit w/ pull string from Camera location on isocenter 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 installed in the conduits for Elekta installed cables?

  Yes

  No

  N/A

• If in-line pull boxes have been installed, there has to be personnel standing by to assist in the pulling of the Elekta supplied cables.

• Has the personnel 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

• Additional comments:

Control Area

• Is all millwork/desks and furniture 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 made of metal (conducting material) must be grounded.

• Are the conduits and cable ducts clean and clear?

  Yes

  No

  N/A

• Do the 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 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 = +22 to +26 °C (+15 °C to +30 °C during rigging) & humidity = less then 50% (30–75% during rigging) 24/7?

  Yes

  No

  N/A

• Elekta recommends +22 to + 26 deg for patient comfort and less than 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 Wi-Fi or LAN network with internet access that our engineers can use during the installation in the control area?

  Yes

  No

  N/A

• What is the SSID (name of the network)? : What is the Password? :

• Additional Comments:

Treatment Planning Area

• Is this a upgrade from older LGP

  Yes

  No

  N/A

• Is there also a SPS installation on the same PC

  Yes

  No

  N/A

• LGP version now:

• Database size:

• Number of patients:

• Is all millwork/desks and furniture 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 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 = +22 to +26 °C (+15 °C to +30 °C during rigging) & humidity = less then 50% (30–75% during rigging) 24/7?

  Yes

  No

  N/A

• Elekta recommends +22 to + 26 deg for patient comfort and less than 50% humidity for optimum equipment operation.

• Are the final lighting and controls installed and operational?

  Yes

  No

  N/A

• Is there a Wi-Fi or LAN network with internet access that our engineers can use during the installation in the control area?

  Yes

  No

  N/A

• What is the SSID (name of the network)? : What is the Password? :

• Additional Comments: