i5 Platform for RF/DSA

Installation Report
Required. InfiMed requires submission of an installation report within 30 days of first clini-
cal use of the i5 system. Copy the form from the following pages, or use InfiMed's website.
On the website, use username generator and password generation5, and go to http://
infimed.com/assets/care_files/documentation/726-105-G1.pdf.

Contact InfiMed Customer Care at +1 315-453-4543 with questions. Thank you.

Installation Report, InfiMed i5 Platform

Service technician: Complete this form to document your installation of the InfiMed i5 Platform.
Return this form to InfiMed (121 Metropolitan Dr., Liverpool, NY 13088 USA) within 30 days of
installation. Enter NA if an item is not applicable.

Installation: ___New ___Reinstalled ___Used Date: ___ / ___ / 20___

System serial number:

Site information Distributor information

Name Name

Street Street
City, State, Zip City, State, Zip

Department administrator Service engineer

Phone Phone

Email Email

Survey completed by (print)

Signed Date

Installation Report: i5 Platform for RF/DSA - 721-009-G1 1

 Room configuration
Bucky replacement _____ Chest stand _____ Table
Positioner type Make Model
High resolution monitor type Make Model
Control station in: _____ Exam area _____ Control area
Are all interface cables clearly labeled? _____ Yes _____ No
Distance from i5 tower PC to patient area _____
Modem telephone number (if any)

Detector setup
Detector manufacturer & model Wireless _____ Yes _____ No
Mfr & model of second panel, if any: Wireless _____ Yes _____ No
X-ray generator
Manufacturer Model
Integrated with i5 Platform _____ Yes _____ No

Installation notes

2 Installation Report: i5 Platform for RF/DSA - 721-009-G1

 Acceptance Tests, InfiMed i5 Platform
Service technician: After completion of each test or procedure, note date that test was completed
as well as the results of test or any other pertinent information. Some items listed are optional
equipment and may not have been installed.Enter NA if an item is not applicable.

Procedure Pass Fail NA

Baseline data on previously installed digital system
System diagnostics
System power up sequence
System configuration complete
System panel calibration complete. Document image quality parameters including noise,
resolution, uniformity, and signal range.
Ion chamber calibration
Image acquisition
Review of acquired images - W/L/I, AIE, flip, rotate, manual shutter, annotation, pointers,
measurements
Print images on DICOM printer
Export patient / image via DICOM network or disc media
Dicom worklist
Import patient from DICOM media
DICOM transfer received
Review or Work Procedures defined in the i5 Platform
Review of Exams defined in the i5 Platform
Review of Positions defined in the i5 Platform

For QA use only

System serial number Installation date
Were any parts damaged in shipment? _____ Yes _____ No
If Yes, record all components that were removed or replaced.

Comments

Installation Report: i5 Platform for RF/DSA - 721-009-G1 3

 Removed component Replacement component
Part name IPN Serial no. Part name IPN Serial no.

4 Installation Report: i5 Platform for RF/DSA - 721-009-G1