If Parts Or Products Are Needed, Identify Below

CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL SOLUTIONS SERVICE REQUISITION MF# 52.1 Rev. B

PURPOSE ASSESSMENT EVALUATION INSTALLATION SERVICE CALL

SuperNova Sink Sonic Washer Cart Washer Container SteriTite FlashTite Loaners In-Service

IF PARTS OR PRODUCTS ARE NEEDED, IDENTIFY BELOW

Product ID Description Estimated Time Cost

IF INDEPENDENT SERVICE IS NEEDED, IDENTITY BELOW

VENDOR NAME CONTACT PHONE EMAIL ASSIGNMENT 1 2 3

APPROVED BY DATE ASSIGNED TO DATE

Issued by: Tania Lupu Revision No. B First Issue Date: 07/22/11 Changed by: MF Revision Date: 7/19/12 File: QC\Master Forms\MF# 52.1 Rev. A Verified & Approved by: TL Date: 7/20/12 CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL SOLUTIONS ASSESSMENT CHECKLIST MF# 120.2 Rev. A FOR MANUAL CLEANING Sink Brand Part # Photo Brand Part # Photo Brand Part # Photo Current Product(s) Used:

Ultrasonic Brand / Model # Serial# Setting Cycle count Brand / Model # Serial# Setting Cycle count Brand / Model # Serial# Setting Cycle count Brand / Model # Serial# Setting Cycle count Current Product(s) Used:

Washer Brand/ Model # Serial # Setting Cycle count Brand/ Model # Serial # Setting Cycle count Brand/ Model # Serial # Setting Cycle count Brand/ Model # Serial # Setting Cycle count Brand/ Model # Serial # Setting Cycle count Brand/ Model # Serial # Setting Cycle count Brand/ Model # Serial # Setting Cycle count Current Product(s) Used:

Cart Washer Brand / Model# Serial # Setting Cycle count Brand / Model# Serial # Setting Cycle count Brand / Model# Serial # Setting Cycle count Brand / Model# Serial # Setting Cycle count Current Product(s) Used:

ASSIGNED TO DATE APPROVED BY DATE TEST PERFORMED / RESULTS Washer Indicator Name Results Water hardness level

Issued by: MF Revision No. A First Issue Date: 09/21/12 Changed by: Revision Date: File: QC\Master Forms\MF# 120.2 Rev A Verified & Approved by: TL Date: 9/21/12 CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL SOLUTIONS INSTALLATION CHECKLIST MF# 120 Rev. F

OBTAIN PO ORDER PRODUCT GATHER PROPORTIONER, UNIVERSAL ADAPTER AND APPROPRIATE METERING TIP GATHER APPROPRIATE COLOR CODED CAP AND ALARM STANDS (REGULAR FOR SINK WIDE MOUTH FOR MACHINE SET UP) ESTABLISH DELIVERY DATE/ TIME LINE COORDINATE WITH BIOMED PERSONNEL AT FACILITY IDENTIFY EACH MACHINE MAKE AND MODEL IDENTIFY SINK AND QUANTITY TO BE INSTALLED PHOTOGRAPH THE SINK IF POSSIBLE ( DETERMINE IF THE ADAPTER IS NEEDED ) ENSURE THAT ALL PRODUCTS WERE RECEIVED BRING TOOL KIT WITH WRENCH, ZIP TIES, TUBING, COLOR CODED TAPE, CHECK VALVE VERIFY WATER QUALITY, TEMPERATURE, PH LEVEL, HARDNESS IDENTIFY WHICH WASH INDICATOR IS USED REFER TO WASHER MANUAL FOR TROUBLESHOOTING BRING 1 GALLON SCHMUTZOFF TO DESCALE HIGHLY SOILED WASHERS IF NECESSARY OBTAIN PACKING LIST INSPECT ALL WASHER EQUIPMENT (SPRAY ARMS, DRAINS, WINDINGS, SCREENS ETC.) COMPLETE MACHINE LOG SETTING FORMS (INTERNAL & EXTERNAL) POST MACHINE SETTINGS POST SINK AND SONIC SIGNS IF REQUESTED INSERVICE STAFF COMPLETE EVALUATION FORM, OBTAIN FEEDBACK ORDER ADDITIONAL PRODUCT AS NEEDED FOLLOW-UP

NOTES OBSERVATIONS SALES GOALS ACTION ITEMS RESULTS COMPLETED BY DATE Issued by: Tania Lupu Revision No. F First Issue Date: 07/22/11 Changed by: MF Revision Date: 9/21/12 File: QC\Master Forms\MF# 120 Rev F Verified & Approved by: TL Date: 9/21/12 CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL MACHINE SETTINGS FOR CUSTOMERS MF# 147.1 Rev.A

MACHINE # INSTRUMENT Temp Time Pump Enz / Det / Lube Rate Recirc CYCLE Pre Wash 1 Enzyme Wash Sonic Wash Rinse Wash 1 Rinse 1 Thermal Rinse Pure Water 1 Drying

MACHINE # INSTRUMENT Temp Time Pump Enz / Det / Lube Rate Recirc SHORT CYCLE Pre Wash 1 Enzyme Wash Sonic Wash Rinse Wash 1 Rinse 1 Thermal Rinse Pure Water 1 Drying

MACHINE # UTENSIL CYCLE Temp Time Pump Enz / Det / Lube Rate Recirc Pre Wash 1 Enzyme Wash Sonic Wash Rinse Wash 1 Rinse 1 Thermal Rinse Pure Water 1 Drying

Serviced By Date Approved By Date Recommendations

Revision No. A Issued by: Tania Lupu Changed by: MF Revision Date: 7/19/12 First Issue Date: 07/22/11 Verified & Approved by: TL Date: 7/20/12 File: QC\Master Forms\MF# 120 Rev E CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL MACHINE LOG SETTINGS MF# 147 Rev. D

MACHINE # INSTRUMENT Temp Time Pump Enz / Det / Lube Rate Recirc. CYCLE From To From To From To From To Pre Wash 1 Enzyme Wash Sonic Wash Rinse Wash 1 Rinse 1 Thermal Rinse Pure Water 1 Drying

Serviced By Date Approved By Date Recommendations

Issued by: Tania Lupu Revision No. D First Issue Date: 07/22/11 Changed by: MF Revision Date: 7/19/12 File: QC\Master Forms\MF# 120 Rev D Verified & Approved by: TL Date: 7/20/12 CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL FIELD REPORT MF# 189 Rev.A Complete all fields below. Rate interest level 1- 5 ( 5 representing high / hot )

PURPOSE ASSESSMENT EVALUATION INSTALLATION SALES CALL GOALS APPROVED BY DATE

TERRITORY REP FACILITY CONTACT INFO PRODUCT FOCUS INTEREST LEVEL OPPORTUNITY TIMELINE $$

FIELD REPORT NOTES OBSERVATIONS SALES GOALS ACTION ITEMS SALES REP RATING COMPLETED BY DATE Issued by: MF Revision No. A First Issue Date: 09/21/12 Changed by: Revision Date: File: QC\Master Forms\MF# 189 Rev A Verified & Approved by: TL Date: 9/21/12 CUSTOMER CUSTOMER CONTACT ADDRESS CITY STATE DEPARTMENT PHONE EMAIL BIOMED CONTACT PHONE DATE INITIATED REQUESTED BY DATE REQUESTED DATE SCHEDULED

CASE MEDICAL EVALUATION TRACKING FORM MF# 101 Rev. C

PRODUCT EVALUATED TIMELINE CLINICAL / PRODUCT SPECIALIST APPROVED BY DATE

SOU DATE COMPLETED BY PO / # DATE COMPLETED BY PRODUCT SENT DATE COMPLETED BY IN SERVICE STAFF DATE COMPLETED BY IN SERVICE SPD DATE COMPLETED BY IN SERVICE OR DATE COMPLETED BY FOLLOW UP DATE COMPLETED BY EVALUATION FORM DATE COMPLETED BY

NOTES OBSERVATIONS SALES GOALS ACTION ITEMS RESULTS COMPLETED BY DATE Issued by: Tania Lupu Revision No. C First Issue Date: 01/12/01 Changed by: MF Revision Date:9/21/12 File: QC\Master Forms\MF# 101 Rev C Verified & Approved by: TL Date: 9/21/12