11 Compliances; Statement Of Compliance From Hospital/Contractor - Brainlab ExacTrac Planning Manual

COMPLIANCES

11 COMPLIANCES

11.1 Statement of Compliance from Hospital/
Contractor
Compliance Form
___________________________________
hereby confirms that (please mark the corresponding items with a "✓" as applicable):
☐ the electrical facility installation is operational and in compliance with applicable safety stand-
ards,
☐ an appropriate number of ropes, rope clips and rope tighteners for the ceiling mounts were
used.
and that all of the following ceiling mounted equipment is installed according to the respective
local regulations and Brainlab pre-installation parameters as described in the ExacTrac Site
Planning Manual:
☐ ceiling mount of the IR camera (n/a for Varian TrueBeam
☐ ceiling mounts of the flat panel detectors
☐ upper part of the ceiling mounted monitor arm
☐ control room distribution box
☐ in-room distribution box
If any non-compliance exists, the hospital takes full responsibility for any possible related future
incidents.
___________________________________
Hospital Representative/Contractor
Name
___________________________________
Hospital Representative/Contractor
Stamp
Site Planning Manual Rev. 1.0 ExacTrac Ver. 6.x

STATEMENT OF COMPLIANCE FROM HOSPITAL/CONTRACTOR

(please print)
(Hospital/Contractor Name)
TM
systems)
___________________________________
Date
___________________________________
Hospital Representative/Contractor
Signature
95