现场检验条件调查表.doc

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1、辽宁省医疗器械检验检测院现场检验检测条件调查表QuestionnaireonTestingSpot1.基本情况（BasicCondition）制造商名称：Manufacturer:生产厂地址：Address:产品名称：Name:型号规格：Model:商标名称：Trademark:真实性承诺：我们承诺《现场检验检测条件调查表》中填写内容真实无误，若有不符，承担由此而产生的一切责任和后果。AuthenticityPromise:Wepromisethat“QuestionnaireonTesting”wefilledinistrulyandinerrable.Ifitdoesnottrulywit

2、htheform,wewilltaketheresponsibilityforallthelegalissueoccurred.填表人签字：印刷体：Filledby:Print:批准人签字：印刷体：Approvedby:Print:(公章)年月日(Seal)date:V7.0LMTI-QSD-D119A-S0辽宁省医疗器械检验检测院2.试验现场条件（TestingSpotCondition）要求：现场试验的场地及相关的电源、通风、照明、电离辐射防护等条件应满足X射线机（CT机）试验的要求。Requirement:Theconditionsoftestingspotonthesite,suppl

3、y,ventilate,lighting,ionizationradiationprotectionshouldmeetthetestingrequirementsofX-rayequipmentCT.试验场地名称及地点：Thenameandaddressoftestingsite:工作面积：m2状态：□独立□局部WorkingareaStateIndependencePart环境温度：℃相对湿度：％□空调□自然状态EnvironmenttemperatureRelativehumidityConditionerNaturecondition通风状况：□空调□自然通风Ventilatedcon

4、ditionConditionerNature照明状况：□人工采光□自然采光LightingconditionSupplyinglightNaturelight电源条件：相数：□单相□三相电源电阻：ΩSupplyconditionPhasesinglephaseTriphasePowerresistance电压：V频率：Hz容量：kWVoltageFrequencyElectricalcapacity电磁干扰的防止：□无干扰源□有干扰源ElectromagneticinterferencepreventionNo-interferenceInterference□有干扰源，但有防止措施Inte

5、rference,buthaspreventionmethod振动噪音的防止：□无噪声源□有噪声源VibrationnoisepreventionNo-noiseNoise□有噪声源、但有改善措施Noise,buthasimprovablemethod保护接地的条件：□有专用接地系统□有临时接地系统ProtectiveearthingconditionSpecialearthingsystemTemporaryearthingsystem□无接地系统No-earthingsystem电离辐射的防护：□永久性防护（隔室操作）□临时防护（防护屏）Ionizationradiationprotect

6、ionPermanenceprotectionTemporaryprotection□无辐射防护No-radiationprotection背景噪声是否符合GB4824要求□是□否BackgroundnoiseisinlinewiththeGB4824requirementsYesNo是否提供背景噪声测试图□是□否ProvidebackgroundnoisetestreportYesNoV7.0LMTI-QSD-D119B-S0辽宁省医疗器械检验检测院3.试验辅助人员（TestingAssistant）要求：应有熟悉标准、检验操作的专业技术人员协助工作。Requirement:Technica

7、lstaffswhoarefamiliarwiththestandardandtestshouldbeassistedwiththework.名称Name性别Sex职务/职称Title专业Major从事专业年限Yearsetthisfield4.试验仪器设备（TestingInstruments）要求：应提供试验所需要的仪器设备。Requirement:Theinstrumentshouldsup