EQUIPMENT EVALUATION FORM


CONTACT INFORMATION

First Name:     Last Name:        
Street Address:                
City:     State:     Zip Code:
Country                
Phone:     E-mail Address:        

EQUIPMENT

MODALITY
Product Name:     Type:  

Manufacturer
Made By:          
Date Of Manufacture     Quantity:  

Options
Quantity:  
Options/Installed Licenses  
Extra Items Included
(e.g Chiller/Workstation/UPS etc.)
 
Software Version  
All Software on Site, including Backups  
Yes      No

if MRI or CT/X-Ray please fill out any questions that apply
MRI Magnet Helium Level and Condition (Cold or warm)  
Tube DOM and Current Slice Count or Mas  

Equipment Current Status/Condition/Removal Path
Equipment Fully Operational  
Yes      No
If not working or needs repair, please explain  
Equipment Physical Condition (1 to 10)
(1-Bad, 10 being Excellent/Like New)
 
Equipment Removal Path
(floor level? hallway removable? Obstacles in Way?)
Please be as descriptive as possible
 

Notes
Additional comments or questions: