DateName of Technician Performing MaintenanceFacilityDevice Manufacturer / Model NumberDevice Serial NumberIs the device being stored empty and free of water?Equipment cleaned following the manufacturer's instructions for use?Was the heater-cooler tubing changed during this cleaning?When was the tubing last changed?If using a LivaNova 3T, was the Aerosol Collection Set changed during this cleaning?H2O2 level measured semi-quantitatively by visual comparison of the reaction zone of a hydrogen peroxide test strip.If using a LivaNova 3T, when was the Aerosol Collection Set last changed?Was a Peroxide (H2O2) analysis performed?Was the Peroxide (H2O2) concentration greater than 100 ppm?Was a water sample obtained and sent for analysis?Date Water Sample ShippedNotes/CertificationsEdit EntryDelete EntryDownload PDF
DateName of Technician Performing MaintenanceFacilityDevice Manufacturer / Model NumberDevice Serial NumberIs the device being stored empty and free of water?Equipment cleaned following the manufacturer's instructions for use?Was the heater-cooler tubing changed during this cleaning?When was the tubing last changed?If using a LivaNova 3T, was the Aerosol Collection Set changed during this cleaning?H2O2 level measured semi-quantitatively by visual comparison of the reaction zone of a hydrogen peroxide test strip.If using a LivaNova 3T, when was the Aerosol Collection Set last changed?Was a Peroxide (H2O2) analysis performed?Was the Peroxide (H2O2) concentration greater than 100 ppm?Was a water sample obtained and sent for analysis?Date Water Sample ShippedNotes/CertificationsEdit EntryDelete EntryDownload PDF