²No.

Date YYYY/MM/DD
CUSTOMER EXPERIENCE REPORT Prepare by
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TO : NIPRO HQS TO : ¹
Approved by
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TITLE
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Pengajuan Sperpat mesin surdial 55 plus
CATEGORY*
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Complaint ü Repair Others :
SALES OFFICE / DISTRIBUTOR PT. Sinar Roda Utama COUNTRY Indonesia
HOSPITAL NAME
Ref. Installation Report
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Number of installed machines
8

ü A/B: Front Pipe ü A: Front Pipe, B: Powder A: Central, B: Powder

SUPPLY OF CONCENTRATE
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A/B: Central A: Central, B: Front Pipe Others

MACHINE INFORMATION
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MODEL SURDIAL55 Plus TYPE INSTALLATION DATE YYYY/MM/DD
SERIAL NUMBER OCCURRENCE DATE YYYY/MM/DD
SOFTWARE VER. RUNNING HOUR(S)
Count of shifts / sessions / cools Periodical inspection ü YES NO
PARTS IMFORMATION ( Please tick on the apropriate item. )
FAILURE PARTS NAME ( Lot/N, Ser/N ) 11
Nipro
(Please add more columns if necessary) Order code Qty RETURN SHIPMENT*
12 13
REPLACEMENT PARTS*

Possible Necessary Qty:

Returned by: Delivered by :

Not Unnecessary
Reason: Already received on:
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
To :
Attention :
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DELIVERY ADDRESS TO
Address :
Phone No :
DETAIL INFORMATION
ERROR CODE* X No Error code observed
Rinse* Preparation Treatment
CONDITION(S) ERROR DETECTED*
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Retrans Stand by Others
Chemical for surface*
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Sodium hypochlorite Peracetic acid Others :
Name of chemical Original conc. Diluted conc. Temperature setting
% % °C
P. 1
 Chemical for
18 √ Sodium hypochlorit Preparation Acetic acid
Hydraulics* √ Citric acid √ Hot citric acid Others :
Name of chemical Original conc. Diluted conc. Temperature setting
1. Sodium Hypochlorit 5.25% 1% 37°C
2. Citric Acid 30% 2% 37 °C
- Auto 1: WTR 7m + DIS 20m + WTR 20m
- Auto 2: WTR 7m + ACD 20m + WTR 20m
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Cleaning Program - Hot citrid 45 m

Between treatment :
End of the day :
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Cleaning Pattern
Mon Auto 1 Tue Auto 1 Wed Auto 2 Thu Auto 1
Fri Auto 2 Sat Auto 2 Sun
TROUBLE DETAILS AND TROUBLE SHOOTING
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BASIC INFORMATION
Influence to patients Non Slight Serious
Did the alarm sound ? Yes No
Light indicator state R Y G B
Frequency State in the same model
Reproducibility after the alarm reset Yes No
Reproducibility after the power OFF-ON Yes No
Has the battery low alarm occurred ? Yes No
1 Trouble details ( including occurrence interval and frequenci etc. 0f error ) if needed, add more space

Q. Did this trouble accur for the first time to this machin ?* √ Yes No
If no, please imform CER No, for the last times :
2 Trouble shooting action If needed, add more space.

3 Current Condition

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PLEASE ATTACH ANY PHOTO HERE OR FROM NEXT PAGE IF YOU HAVE. (History, Pressure graph ect. )

QUALITY REPORT ( This column will be filled by the factory after the investigation )
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QUALITY REPORT NO. Please refer to No.

ANY COMMENT
 Rev. 2015. 12. 01
P.2