Biomedical Equipment Information Form printable pdf download

Atlantic Veterinary College - Biomedical Equipment Information Form

1) Purchase Initiator

AVC Dept:___________________________________ Name: ____________________________________

_____

Phone #:_________________________ Fax #:_______________________ Date:________________

2) To be completed by vendor or purchase initiator - Forward copy with purchase requisition to

purchasing office

Equipment:

_______________________________

Model: ________________________________

Manufacturer:

_____________________________

Supplier:______________________________

Address:

_____________________________

Address: ______________________________

_____________________________

______________________________

_____________________________

______________________________

Phone:

_____________________________

Phone: ______________________________

Fax:

_____________________________

Fax:

_____________________________

Contact Person _____________________________

Contact Person:_________________________

To which applicable safety standard is the equipment certified: CSA/UL Canada/Entella Other:_______________

Are service manuals included in the purchase price? Yes/No Cost: $______________ Part #________________

(Except for unusual circumstances service manuals must be obtained with initial purchase)

Warranty Period: _______ Months/Years

Are all accessories included in warranty (probes, etc)? Yes/No

Does warranty include Parts? Yes/No

Labour? Yes/No

Onsite service? Yes/No

Special installation requirements (power, water, ventilation, gasses, etc) _________________________________

Any additional warranty details: (preventative maintenance, etc.) _______________________________________

Vendor installs equipment? Yes/No

Is technical support available? Yes/No

Tech support #________________

Is factory service training available? Yes/No

Additional cost for training: $______________

If service contract purchased after warranty period:

Cost of service contract: $___________________

Contract details: Period of coverage ______ Months/Years

Are any items not covered? Yes/No

Additional contract details _________________________________________________________________

If service contract not purchased after warranty period:

Hourly rate for service: $_________/hr

Additional travel charges for service: $____________

______

Signature:____________________________________________

Date: _______________________

3) Internal: Purchaser to complete at time of installation/delivery and forward to Biomedical Engineering

UPEI Purchase Order Number: ________________ Amount: $_______________ Date Received: ______________

Serial #_____________________ Model (if different than above):___________________ Location: ____________

Description: __________________________________________________________________________________

Software Version (if applicable): __________________ Individual Responsible: ____________________________

Biomedical Equipment Information Form

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