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System ID:
SR#:
Date:
(Revolution) ACT / ACTs (SVCT16) PM Form
Customer Name:
Service Record #: System ID or Serial #:
Customer Equipment ID: Service Manual Doc #:
Software Version: PM Frequency: Quarterly
Service Type: Form Status:
Start Date: Country:
Schedule A Schedule B Schedule C Schedule W Schedule - Optional HHS Scan Data
PM Schedule A
Preliminary Requirements
Task Results Comments
Indicate the last PM inspection date
Indicate the last schedule completed
List any tasks completed earlier as part
of a service action
System Application Stop and Start
Errors
Linux Reboot and Shutdown Errors
Record Gantry Rotations
Initial Procedures
System Temperature and Humidity Limits
Recom- Low High Measured If Adj or
Task Results Comments
mended Spec Spec as Found NA
Measure ambient scan/control room
temperature (record here in °F or
record in °C below).
Measure ambient scan/control room
temperature (record here in °C or
record in °F above).
Measure ambient non-condensing
relative humidity (%).
General Gantry Inspection
Task Results Comments
Listen for Unusual Noises
System ID:
SR#:
Date:
Task Results Comments
Test Display Lights
Test E-stops
Laser Alignment Inspection
Task Results Comments
Internal / External Alignment Lights
External Axial / Internal Axial Distance
Coronal Alignment Lights
Gantry Power Off (Covers Off)
General Tasks
Task Results Comments
Emergency Off Switch
UPS Power Off Inspection
Gantry Cover Cables Inspection
Slip Ring & Brush Block Inspection and Maintenance
Task Results Comments
Remove Slip Ring Brush Debris
Slip Ring Tracks Inspected
CleanBrush Blocks
Brush Tip Inspection
Gantry Filter Cleaning
Task Results Comments
Clean Top Cover Fans
Inspect Rotating Path Components & Cables
Clean Detector Module Surface Foam
System ID:
SR#:
Date:
Gantry Power On (Covers Off)
Tube Heat Exchanger & Generator Fan Inspection
Task Results Comments
Inspect / Clean Tube Heat Exchanger
Inspect / Clean Djinn Inverter Fan
General Tasks
Task Results Comments
UPS Powered and Operational
No. Revs since last
Task Results Comments
greasing
Grease Gantry Main
Bearing
Gantry Power On (Covers On)
General Tasks
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)
Series 3 (Helical/Auto Voice)
General Tasks
System ID:
SR#:
Date:
Task Select Comments
X-ray On Indicators
Scan Control Pushbuttons Test
Finishing Up
Task Pass Fail Comments
Site Log Updated
PM Paper work completed for this site
Comments:
No measurement tools needed
Characters Remaining: 1,973
Tools Used:
Description Serial Number Bar Code/ Asset Tag Cal Due Date
Add Tool
Remove Tool
GE Representative:
Number of Signers
Name:
SSO #:
SR #:
System ID:
SR#:
Date:
Yes Not Required
Customer Signature:
Date Complete
Form Complete
System ID:
SR#:
Date:
Revolution ACTs (SVCT8) PM Forms
Customer Name:
Service Record #: System ID or Serial #:
Customer Equipment ID: Service Manual Doc #:
Software Version: PM Frequency:
Service Type: Form Status:
Start Date: Country:
Schedule(s) Selected
Schedule A Schedule B Schedule C Schedule W Schedule - Optional HHS Scan Data
PM Schedule B
Preliminary Requirements
Task Readings Results Comments
Indicate the last PM inspection date.
Indicate the last schedule completed.
List any tasks completed earlier as part of a
service action.
Record the number of gantry revolutions.
Completed Tasks
Task Results Comments
Review Error Logs.
System Application Stop and Start Errors
Linux Reboot and Shutdown Errors
Initial Procedures
System Temperature and Humidity Limits
Recomm- Low High Measured If Adj or
Task Pass/Fail Comments
ended Spec Spec as Found NA
Measure ambient scan/control room
temperature (record here in °F or
record in °C below).
System ID:
SR#:
Date:
Recomm- Low High Measured If Adj or
Task Pass/Fail Comments
ended Spec Spec as Found NA
Measure ambient scan/control room
temperature (record here in °C or
record in °F above).
In the control room, measure
ambient non-condensing relative
humidity (%).
Console Cleaning & Inspection
Task Results Comments
Inspect Console.
Clean console monitor and components.
General Gantry Tasks
Task Results Comments
Listen for unusual noises.
Test display lights.
Test E-stop buttons.
Inspect collimator - check bowtie filter.
SVCT PDU Tasks
Task Data Results Comments
Using a DVM check the main input power.
Measure the line to line voltages at L1, A, B, and
C. Record the highest line to line voltage.
Using a DVM check the main input power.
Measure the line to line voltages at L1, A, B, and
C. Record the lowest line to line voltage.
Verify the highest line to line voltage does not
exceed 1.02 times the lowest voltage.
SVCT PDA Tasks (Optional)
System ID:
SR#:
Date:
Task Data Results Comments
Remove the SVCT PDA front cover. Using a
DVM, check and record the main input power.
Power OFF, Gantry Covers OFF
General Power Tasks
Task Results Comments
Confirm UPS Power is disconnected.
Verify the Emergency Switch is OFF.
Slip Ring & Brush Block Inspection & Maintenance
Task Results Comments
Inspect the brush block and brushes.
Remove slip ring brush debris.
Complete Gantry Filter Cleaning.
Using pure alcohol, clean the detector foam (replace if necessary).
Gantry Filter Tasks
Task Results Comments
Clean top cover fans.
Inspect Rotating Path Components & Cables.
CT Belt Tension & Adjustement
Task Results Comments
Inspect and adjust tension belt.
SVCT PDU Tasks
Task Data Results Comments
Complete the SVCT PDU Inspection.
System ID:
SR#:
Date:
Task Data Results Comments
Note the SVCT PDU model number.
Note the SVCT PDU serial number.
SVCT PDA Tasks (Optional)
Task Data Results Comments
Complete the SVCT PDA Inspection.
Note the SVCT PDA model number.
Note the SVCT PDA serial number.
Gantry Power ON (Covers OFF)
Gantry Tasks
Task Results Comments
UPS powered and operational.
Inspect/clean the Tube Heat Exchanger.
Inspect/clean the Djinn Inverter Fan.
Gantry Tasks
Task Readings Results Comments
Check Gantry Main Bearing*
*If it has been longer than one year, grease the
gantry main bearing.
Record the number of gantry revolutions since the
gantry bearing was last greased.*
*If the number of revolutions is greater than
2,000,000, grease the gantry main bearing.
Power ON, Gantry Covers ON
Table Tasks
System ID:
SR#:
Date:
Task Results Comments
Complete General Table Cleaning and Inspection.
General Tasks
Task Results Comments
Install/inspect scan window for physical damage.
Inspect Rotational Clearances.
System Scanning Test
QA Phantom
Task Location Gantry Serial #
Serial #
Scans Results Artifacts Artifact Types/Comments
Series 1 (Scout/Auto Voice)
Series 2 (Axial)
Series 3 (Helical/Auto Voice)
Final Checks
Task Complete Not Complete Comments
Check X-Ray ON indicators.
Test scan control push-buttons.
GIB Updates Completed
Update site log.
Complete site paper work.
Follow-Up
PM Check No Yes Comments (Service Schedule Date)
Is follow-up work required?
Comments:
System ID:
SR#:
Date:
Characters Remaining:
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 #:
Date Complete
Form Complete
System ID:
SR#:
Date:
Revolution ACTs (SVCT8) PM Forms
Customer Name:
Service Record #: System ID or Serial #:
Customer Equipment ID: Service Manual Doc #:
Software Version: PM Frequency:
Service Type: Form Status:
Start Date: Country:
Schedule(s) Selected
Preliminary Requirements
Schedule A Schedule B Schedule C Schedule W Schedule - Optional HHS Scan Data
PM Schedule C
Task Procedure Results Comments
Indicate the last PM Inspection Date.
Indicate the last schedule completed.
List any tasks completed earlier as part of a
service action.
Inspect the console error logs.
Record the number of gantry revolutions.
Completed Tasks
Task Results Comments
Review Error Logs.
System Application Stop and Start Errors
Linux Reboot and Shutdown Errors
Initial Procedures
System Temperature and Humidity Limits
Low High Measured If Adj or
Task Procedure Pass/Fail Comments
Spec Spec as Found NA
System ID:
SR#:
Date:
Low High Measured If Adj or
Task Procedure Pass/Fail Comments
Spec Spec as Found NA
Measure ambient scan/control room
temperature (record here in °F or
record in °C below).
Measure ambient scan/control room
temperature (record here in °C or
record in °F above).
Measure ambient non-condensing
relative humidity (%).
Console Cleaning & Inspection
Task Results Comments
Inspect Console.
Clean console monitor and components.
General Gantry Tasks
Task Results Comments
Listen for unusual noises.
Test display lights.
Test E-stop buttons.
Inspect Collimator - check bowtie filter.
Power OFF, Gantry Covers OFF
General Power Tasks
Task Results Comments
Confirm UPS Power is disconnected & verify the Emergency
Switch is OFF.
Slip Ring & Brush Block Inspection & Maintenance
Task Results Comments
Inspect the brush block and brushes.
Remove slip ring brush debris.
System ID:
SR#:
Date:
Task Results Comments
Complete Gantry Filter Cleaning.
Using pure alcohol, clean the detector foam (replace if necessary).
Gantry Filter Tasks
Task Results Comments
Power ON, Gantry Covers OFF
Gantry Tasks
Clean top cover fans.
Inspect Rotating Path Components & Cables.
Task Results Comments
UPS powered & operational.
Inspect/clean the Tube Heat Exchanger.
Inspect/clean the Djinn Inverter Fan.
Gantry Tasks
Task Readings Results Comments
Check Gantry Main Bearing*
*If it has been longer than one year, grease the
gantry main bearing.
Record the number of gantry revolutions since the
gantry bearing was last greased.*
*If the number of revolutions is greater than
2,000,000, grease the gantry main bearing.
Complete the gantry verification procedure titled
"Smart kV Procedure", (applicable to software
versions 16IWxx & above).
Complete meter verification.
Power ON, Gantry Covers ON
System ID:
SR#:
Date:
General Tasks
Task Results Comments
Install/inspect scan window for physical damage.
Inspect Rotational Clearances.
System Scanning Test
QA Phantom
Task Location Gantry Serial #
Serial #
Scans Results Artifacts Artifact Types/Comments
Series 1 (Scout/Auto Voice)
Series 2 (Axial)
Series 3 (Helical/Auto Voice)
HHS Scan Data
Task Results Comments
If you are required to complete these tests, record the readings in
Appendix A of this documents.
Final Checks
Task Complete Not Complete Comments
Check X-Ray ON indicators.
Test scan control push-buttons.
Quality Assurance Test
Record GE Phantom Serial # in Tools Used area
Update site log.
Complete site paper work.
Follow-Up
PM Check No Yes Comments (Service Schedule Date)
Is follow-up work required?
System ID:
SR#:
Date:
Comments:
Characters Remaining:
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 #:
Date Complete
Form Complete
System ID:
SR#:
Date:
Revolution ACTs (SVCT8) PM Forms
Customer Name:
Service Record #: System ID or Serial #:
Customer Equipment ID: Service Manual Doc #:
Software Version: PM Frequency:
Service Type: Form Status:
Start Date: Country:
Schedule(s) Selected
Schedule A Schedule B Schedule C Schedule W Schedule - Optional HHS Scan Data
PM Schedule A
Preliminary Requirements
Task Measure Results Comments
Indicate the last PM inspection date.
Indicate the last schedule completed.
List any tasks completed earlier as part of a
service action.
Inspect the console error logs.
Record the number of gantry revolutions.
Initial Procedures
Completed Tasks
Task Results Comments
Review Error Logs.
System Application Stop and Start Errors
Linux Reboot and Shutdown Errors
System ID:
SR#:
Date:
System Temperature and Humidity Limits
Recom- Low High Measured If Adj or
Task Pass/Fail Comments
mended Spec Spec as Found NA
Measure ambient scan/control room
temperature (record here in °F or
record in °C below).
Measure ambient scan/control room
temperature (record here in °C or
record in °F above).
Measure ambient non-condensing
relative humidity (%).
Console Cleaning & Inspection
Task Complete Not Complete Comments
Inspect console.
Clean console monitor.
General Gantry Inspection
Task Results Comments
Listen for unusual noises.
Test display lights.
Test E-Stop buttons.
Complete a Laser Alignment Inspection.
Gantry Power OFF (Covers OFF)
General Power Tasks
Task Results Comments
Confirm UPS power is disconnected, check Emergency Off Switch.
Perform Gantry Cover Cable Inspection.
Slip Ring & Brush Block Inspection & Maintenance
Task Results Comments
Inspect the brush block and brushes.
Remove slip ring brush debris.
Complete Gantry filter Cleaning.
System ID:
SR#:
Date:
Task Results Comments
Complete rotational checks - clean the top cover fans.
Clean the detector foam using pure Alcohol (replace foam if
necessary).
Gantry Filter Tasks
Task Results Comments
Clean top cover fans.
Inspect Rotating Path Components & Cables.
Power ON, Gantry Covers OFF
Gantry Tasks
Task Results Comments
UPS powered and operational.
Inspect/Clean Tube Heat Exchanger.
Inspect/Clean Djinn Inverter Fan.
Gantry Tasks
Task Readings Results Comments
Check Gantry Main Bearing*
*If it has been longer than one year, grease the
gantry main bearing.
Record the number of gantry revolutions since the
gantry bearing was last greased.*
*If the number of revolutions is greater than
2,000,000, grease the gantry main bearing.
Power ON, Gantry Covers ON
General Tasks
Task Results Comments
Install/Inspect Scan Window.
Check scan window for physical damage.
Inspect Rotational Clearances.
System ID:
SR#:
Date:
System Scanning Test
QA Phantom
Task Location Gantry Serial #
Serial #
Scans Results Artifacts Artifact Types/Comments
Series 1 (Scout/Auto Voice)
Series 2 (Axial)
Series 3 (Helical/Auto Voice)
Final Checks
Task Complete Not Complete Comments
Check X-Ray ON indicators.
Test scan control push-buttons.
Update site log.
Complete site paper work.
Follow-Up
PM Check No Yes Comments (Service Schedule Date)
Is follow-up work required?
Comments:
Characters Remaining:
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 #:
Date Complete
Form Complete