Field Service Performance Verification Record Form

Forcetriad
DC00087444 Revision B Page 1 of 4

Serial Number: _______________________ Date Received: ______________________

Hospital / Organization: ____________________ Software Version Pre___________________
Service Report: __________________________ Software Version Post: _________________

RMA Number: ___________________☐ N/A

Initial Inspection Accept Y/N Power Up Check Accept Y/N

Rear-panel Internal-component inspection N/A
Front-panel System self-check
Footswitch Verify Audio - Tone audible at high
Power-cord and low ranges
Low-Voltage Power Supply
Voltage (GND TP82) Specification Reading
+5 Vdc (TP81) 5.00 to 5.20 Vdc
+12 Vdc (TP83) +11.40 to +13.20 Vdc
-12 Vdc (TP90) -12.36 to -11.64 Vdc
Safety Test in Accordance with IEC 60601-1 (Electrical Safety Testing)
Forcetriad Ground Bond Chassis or Earth Chassis or Earth
Testing Leakage NC Leakage NO
< 0.20 Ω <100µA <500µA

Output Receptacle Output Receptacle Output Receptacles

and REM Source and REM Source and REM Sink
Current Current Current (Mains on
NC <10µA NO <50µA Applied Parts) <50µA
Monopolar 1 Center Tine
Monopolar 1 Right Tine
Monopolar 2 Center Tine
Monopolar 2 Right Tine
Bipolar Left Tine
Bipolar Right Tine
Ligasure 1 Left Tine
Ligasure 1 Right Tine
Ligasure 2 Left Tine
Ligasure 2 Right Tine
UFP Port
REM
REM Function Y/N Automatic Mode Y/N
Green indicator at 120 Ω RF generation at 20W with 25Ω connected
Audible tone at >128Ω & < RF generation stop when disconnected
142Ω
Green indicator at 60 Ω RF generation at 20W with 940Ω connected
Audible tone >77Ω and <91Ω RF generation stop when disconnected
Green indicator at 30Ω RF generation at 20W with 1070Ω connected
Green indicator at 10Ω
Red indicator before 1Ω
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 Field Service Performance Verification Record Form
Forcetriad
DC00087444 Revision B Page 2 of 4

Serial Number: ________________________

Verifying Autobipolar Function Y/N Footswitch Mode Y/N

Power at 20W RF generation on/off w/o 45Ω connected
Cross Coupling 200Ω
Energy Channel Tested Energy Mode/Effect Specifications Reading
Mono 2 Cut 0 to 140 mA
Monopolar 1
Mono 2 Coag Spray 0 to 140 mA
Mono 2 Cut 0 to 140 mA
UFP
Mono 2 Coag Spray 0 to 140 mA
Mono 1 Cut 0 to 140 mA
Monopolar 2
Mono 1 Coag Spray 0 to 140 mA
Mono 1 Cut 0 to 140 mA
Bipolar
Mono 1 Coag Spray 0 to 140 mA
Mono 1 Cut 0 to 140 mA
LigaSure 1
Mono 1 Coag Spray 0 to 140 mA
LigaSure 2 Mono 1 Cut 0 to 140 mA
Mono 1 Coag Spray 0 to 140 mA
Power Delivery at Receptacle
Power Energy Mode/Effect Specifications Reading
100 Ω Low at 95W 900 to 1044 mA
Bipolar
100 Ω Standard 900 to 1044 mA
(Bipolar FTSW)
100 Ω Macro 900 to 1044 mA
Monopolar 1 300 Ω Cut Pure at 300W 922 to 1072 mA
(2-button HDSW) 500 Ω Coag Spray at 120W 452 to 525 mA
Monopolar 2 300 Ω Cut Pure at 300W 922 to 1072 mA
(2-button HDSW) 500 Ω Coag Spray at 120W 452 to 525 mA
UFP 300 Ω Cut Pure at 300W 922 to 1072 mA
(Monopolar FTSW) 500 Ω Coag Spray at 120W 452 to 525 mA
300 Ω Cut 922 to 1072 mA
Monopolar 1
(Force TriVerse) 300 Ω VL Mode 753 to 876 mA
500 Ω Coag 452 to 525 mA
300 Ω Cut 922 to 1072 mA
Monopolar 2
300 Ω VL Mode 753 to 876 mA
(Force TriVerse)
500 Ω Coag 452 to 525 mA

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 Field Service Performance Verification Record Form
Forcetriad
DC00087444 Revision B Page 3 of 4

Serial Number: ________________________

Power Output – Bipolar - 100 Ω

Low 291 to 339 mA
10 Watt Standard 291 to 339 mA
Macro 291 to 339 mA
Low 504 to 587 mA
30 Watt Standard 504 to 587 mA
Macro 504 to 587 mA
Low 900 to 1044 mA
95 Watt Standard 900 to 1044 mA
Marco 900 to 1044 mA
Power Output - Testing Cut Output - 300 Ω
Prue 146 to 218 mA
10 Watt
Blend 146 to 218 mA
Pure 461 to 536 mA
75 Watt
Blend 461 to 536 mA
300 Watt Prue 922 to 1072 mA
200 Watt Blend 753 to 876 mA
Power Output – Testing Valleylab Mode Output – 300 Ω
10 Watt VL Mode 146 to 218 mA
75 Watt VL Mode 461 to 536 mA
200 Watt VL Mode 753 to 876 mA
Power Output – Testing Coag Output 500 Ω
Fulgurate 20 to 100mA
1 Watt
Spray 20 to 100mA
Fulgurate 226 to 263 mA
30 Watt
Spray 226 to 263 mA
Fulgurate 452 to 525 mA
120 Watt
Spray 452 to 525 mA
Power Output – Test LigaSure Output – 50 Ω
LigaSure 1 LigaSure 2
1A 288 to 355 mA
LigaSure 2.7 A 761 to 885 mA
5.5 A 1540 to 1790 mA
High-Frequency Leakage 200Ω
Power Energy Mode/Effect Specifications Reading
Cut Prue 0 to 100 mA
Cut Blend 0 to 100 mA
UFP Leakage HWD 0 to 100 mA
COAG Fulgurate 0 to 100 mA
COAG Spray 0 to 100 mA

This document is electronically controlled M e dt ronic Cont rolle d Inform a t ion

 Field Service Performance Verification Record Form
Forcetriad
DC00087444 Revision B Page 4 of 4

Serial Number: ________________________

Cut Prue 0 to 100 mA

Cut Blend 0 to 100 mA
Monopolar 1 Leakage HWD 0 to 100 mA
COAG Fulgurate 0 to 100 mA
COAG Spray 0 to 100 mA
Cut Prue 0 to 100 mA
Cut Blend 0 to 100 mA
Monopolar 2 Leakage HWD 0 to 100 mA
COAG Fulgurate 0 to 100 mA
COAG Spray 0 to 100 mA
Bipolar Standard (left tine) 0 to 69 mA
Bipolar Macro (left tine) 0 to 69 mA
Bipolar Low (left tine) 0 to 69 mA
Bipolar Leakage
Bipolar Standard (right tine) 0 to 69 mA
Bipolar Macro (right tine) 0 to 69 mA
Bipolar Low (right tine) 0 to 69 mA
LigaSure (left tine) 0 to 130 mA
LigaSure 1 Leakage
LigaSure (right tine) 0 to 130 mA
LigaSure (left tine) 0 to 130 mA
LigaSure 2 Leakage
LigaSure (right tine) 0 to 130 mA
Cut Prue 0 to 100 mA
Cut Blend 0 to 100 mA
Patient Return Leakage
HWD 0 to 100 mA
COAG Fulgurate 0 to 100 mA
COAG Spray 0 to 100 mA

Field Service Engineer: Date:

This document is electronically controlled M e dt ronic Cont rolle d Inform a t ion