System ID:

SR#:
Date:

PM Report Schedule B
Customer Name:
Service Record #: System ID or Serial #:
Customer Equipment ID: Service Manual Doc #:
Software Version: PM Frequency:
Form Status: Not Complete Start Date:
System Type: Country:

Preliminary Tasks - Last PM Inspection:

Last Inspection Date : Last Schedule Completed:

List any Schedule B tasks that were completed earlier

PM A PM B PM C PM W Optional HHS Scan Data

PM Schedule Sys B
Initial Procedures
Check Temperature and Humidity

Room Temperature Humidity Results Comments

Scan room Temp & Humidity

General Gantry Inspection

Task Results Comments

Test Display Lights

Test E-stops

Test Patient Tilt Sensors

Laser Alignment Inspection

Task Results Comments

Internal Alignment Lights

External Axial to Internal Axial Distance

System Options Inspection

Document #: DOC0969010 Revision: 9 © 2016, General Electric Company

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 System ID:
SR#:
Date:

Task Results Comments

Cardiac Option Inspection

Nemoto Injector Inspection

Collimator Inspection

Task Results Comments

Aperture and Filter Positions and Operation

Protective Window & Opening, Inspected/
Cleaned

Phantom Inspection

Task Results Comments

QA Phantom Inspection

Gantry Power Off (Covers Off)

General Tasks

Task Value Results Comments

Gantry Tilt Zero Check

Task Results Comments

Emergency Off Switch (on wall)

UPS Power Off Inspection

General Console Cleaning & Inspection

Task Results Comments

Clean Component Filters, Fans & Grills

Visual Fan Inspection

Seismic Anchor Check (if necessary)

Slip Ring & Brush Block Inspection and Maintenance

Document #: DOC0969010 Revision: 9 © 2016, General Electric Company

All Rights Reserved

Sheet 2 of 6
 System ID:
SR#:
Date:

Task Results Comments

Remove Slip Ring Brush Debris

Slip Ring Tracks Inspected

CleanBrush Blocks

Brush Tip Inspection

CT Belt Tension & Adjustment

Task Inspected Results Comments

Inspect and Adjust Tension Belt

Gantry Filter Cleaning

Task Results Comments

Clean DAS Detector Plenum Filter

Clean Detector Face Plate

Clean Gantry Heater Filter

Clean Top Cover Fans

Inspect Rotating Path Components & Cables

HV Cable Candle Stick Inspection

Task Inspected Results Comments

Inspect HV Cable Candle Stick

Hydraulic Tilt Pump (Inspect for Leaks)

Task Results Comments

Hydraulic Tilt Cylinder & Fittings

Hydraulic Tilt Pump & Reservoir

NGPDU

Document #: DOC0969010 Revision: 9 © 2016, General Electric Company

All Rights Reserved

Sheet 3 of 6
 System ID:
SR#:
Date:

Task Results Comments

Vacuum Covers & Inside PDU

Inspect Electronic Components

Torque all Connectors

Inspect Seismic Anchor Bolts

Encoder

Task Results Comments

Inspect Rotational Encoder Wheel

Date Last
Task Results Comments
Replaced
Encoder Replacement

Gantry Power On (Covers Off)

General Tasks

Task Results Comments

UPS Powered and Operational

Plenum Fans (5) Operational

No. Revs
Task since last Results Comments
greasing

Grease Gantry Main Bearing

Tube Heat Exchanger & Pump

Task Results Comments

Inspect/Clean Tube Heat Exchanger

Inspect/Clean JEDI Inverter Fan

Gantry Power On (Covers On)

General Tasks

Document #: DOC0969010 Revision: 9 © 2016, General Electric Company

All Rights Reserved

Sheet 4 of 6
 System ID:
SR#:
Date:

Task Results Comments

Scan Window Inspection/Replacement

Inspect Rotational Clearances

Finalization
System Scanning Test
QA Phantom
Task Location Gantry Serial #
Serial #

Scans Scan Failures Artifacts Comments

Series 1 (Scout/Auto Voice)

Series 2 (Axial/Tilt)

Series 3 (Helical/Auto Voice

Task Select Comments

X-ray On Indicators

Scan Control Pushbuttons Test

Finishing Up

Task Pass Fail Comments

Update Site Log

Complete PM Paper Work

Complete Customer Reports

Is follow-up work required? Service Scheduled Date:

This inspection passed and meets all GE Healthcare PM specifications

Comments:

Characters Remaining:

Document #: DOC0969010 Revision: 9 © 2016, General Electric Company

All Rights Reserved

Sheet 5 of 6
 System ID:
SR#:
Date:

Tools Used:

Description Serial Number Bar Code/ Asset Tag Cal Due Date
Add Tool

Remove Tool

GE Representative:

Number of Signers 1

Name:
SSO #:
SR #:

Signature

Customer Signature: Yes Not Required

Date Complete

Form Complete

Save

Document #: DOC0969010 Revision: 9 © 2016, General Electric Company

All Rights Reserved

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