ሚሊንየም ኮቪድ -19 ህሙማን ህክምና ማእከል

Millennium Covid-19 Care Center

Oxygen manifold validation and verification

HOSPITAL _____________________________ DATE__________

CONTRACRTOR _____________________________

Tests to be performed according to HTM 02-01 miniature

System functional test

Section Test performed Result

Manifold operating
performance
Manifold out let pressure
regulation
Safety valve & discharge pipe
performance
Pressure regulators safety and
performance
Service valve function test
Manifold auto changing test
Reverse flow test
Pressure sensors function test
Pressure gauges function test
Check heating ,vibration,
spark ,smelling during test
hours
Test during electric line supply
and emergency operation
Functionality checkup and
regulation
Configuration and adjustment
test
Functional test
Areal alarm units and solenoid
integrity check up
Service valve and solenoid area
Reactions to rapid change in
pressure
Reaction to rapid change in
pressure

Contractor’s representative

Status __________________ name ______________________

Validation__________________ sign ______________________

Contract supervisor

Status __________________ name ______________________

Validation __________________ sign ______________________

Hospital representative

Status __________________ name _____________________

Validation __________________ sign _____________________

P.O BOX 1271 ADDIS ABABA ETHIOPIA

 ሚሊንየም ኮቪድ -19 ህሙማን ህክምና ማእከል
Millennium Covid-19 Care Center
Oxygen manifold validation and verification

HOSPITAL _____________________________ DATE__________

CONTRACRTOR _____________________________

System performance test

Section Test Result

Check each manifold operates Performance test
as designed
Check the emergency manifold Performance test
for correct operation
Test the non-electric emergency Performance test
system operation
Test pipe line and terminal unit Flow performance
flow as designed
Terminal test for gas specificity Tight mount and secure lock

Contractor’s representative

Status __________________ name ______________________

Validation__________________ sign ______________________

Contract supervisor

Status __________________ name ______________________

Validation __________________ sign ______________________

Hospital representative

Status __________________ name _____________________

Validation __________________ sign _____________________

II

Oxygen manifold validation and verification

P.O BOX 1271 ADDIS ABABA ETHIOPIA

 ሚሊንየም ኮቪድ -19 ህሙማን ህክምና ማእከል
Millennium Covid-19 Care Center
HOSPITAL _____________________________ DATE__________
CONTRACRTOR _____________________________

Areal valve service units (AVSU) functional test

Position(labeling) Test pressure Pressure difference

Contractor’s representative

Status __________________ name ______________________

Validation__________________ sign ______________________

Contract supervisor

Status __________________ name ______________________

Validation __________________ sign ______________________

Hospital representative

Status __________________ name _____________________

Validation __________________ sign _____________________

III

P.O BOX 1271 ADDIS ABABA ETHIOPIA

 ሚሊንየም ኮቪድ -19 ህሙማን ህክምና ማእከል
Millennium Covid-19 Care Center
Oxygen manifold validation and verification

HOSPITAL _____________________________ DATE__________

CONTRACRTOR _____________________________

Leakage test

Sectioned area Test pressure Testing time Pressure difference

Contractor’s representative

Status __________________ name ______________________

Validation__________________ sign ______________________

Contract supervisor

Status __________________ name ______________________

Validation __________________ sign ______________________

Hospital representative

Status __________________ name _____________________

Validation __________________ sign _____________________

IV

P.O BOX 1271 ADDIS ABABA ETHIOPIA

 ሚሊንየም ኮቪድ -19 ህሙማን ህክምና ማእከል
Millennium Covid-19 Care Center
Oxygen manifold validation and verification

HOSPITAL _____________________________ DATE__________

CONTRACRTOR _____________________________

Warning and alarming system

Alarm Test Result

Alarm signal status
Reaction to normal and fault
conditions
Labeling and zonal marking
Check all functions operate
correctly
function within specified
tolerance limit with specific
fault condition
Performance in changing
pressure ranges
Clear and easy understandable
Alarm indicator light and sound
test

Contractor’s representative

Status __________________ name ______________________

Validation__________________ sign ______________________

Contract supervisor

Status __________________ name ______________________

Validation __________________ sign ______________________

Hospital representative

Status __________________ name _____________________

Validation __________________ sign _____________________

Oxygen manifold system validation and verification document

HOSPITAL _____________________________ DATE__________

CONTRACRTOR _____________________________

P.O BOX 1271 ADDIS ABABA ETHIOPIA

 ሚሊንየም ኮቪድ -19 ህሙማን ህክምና ማእከል
Millennium Covid-19 Care Center
System function and operation certification according to HTM02-01 miniature

Validation of installation prior to design ______________________

Validation of distribution line ______________________________

Validation of warning and alarm system ______________________

Provision of terminal units and AVSU _______________________

Certification result ________________________

Description ______________________________________________________

_____________________________________________________________________
_____________________________________________________________________

Contractor’s representative

Status __________________ name ______________________

Validation__________________ sign ______________________

Contract supervisor

Status __________________ name ______________________

Validation __________________ sign ______________________

Hospital representative

Status __________________ name _____________________

Validation __________________ sign _____________________

VI

P.O BOX 1271 ADDIS ABABA ETHIOPIA