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AX Systems
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Installation Protocol
System

Installation Certificate
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© Siemens 2004
The reproduction, transmission or use
of this document or its contents is not
permitted without express written
authority. Offenders will be liable for
damages. All rights, including rights
created by patent grant or registration
of a utility model or design, are
reserved.

Print No.: AX00-000.813.01.03.02 English

Replaces: AX00-000.813.01.02.02 Doc. Gen. Date: 05.08
2 Revision / Disclaimer

Document revision level

1Revision / Disclaimer

The document corresponds to the version/revision level effective at the time of system
delivery. Revisions to hardcopy documentation are not automatically distributed.
Please contact your local Siemens office to order current revision levels.

Disclaimer
The installation and service of equipment described herein is to be performed by qualified
personnel who are employed by Siemens or one of its affiliates or who are otherwise autho-
rized by Siemens or one of its affiliates to provide such services.
Assemblers and other persons who are not employed by or otherwise directly affiliated with
or authorized by Siemens or one of its affiliates are directed to contact one of the local
offices of Siemens or one of its affiliates before attempting installation or service proce-
dures.

AX Systems AX00-000.813.01.03.02 Page 2 of 6 Siemens

05.08 AX SCM
Installation Certificate 3
2Installation Certificate

System Model: _____________________________________________________

Order No.: _____________________________________________________
Customer: _____________________________________________________
Installation Loca- _____________________________________________________
tion:
Installation Team: _____________________________________________________
Start of Installation: _____________________ End of ___________________
Installa-
tion:

Siemens AX00-000.813.01.03.02 Page 3 of 6 AX Systems

05.08 AX SCM
4 Installation Certificate

Mechanical Installation Per- Torque values set per the

formed Installation Instructions1
System Compo-
yes no nents not Con- yes
figured

Monitor Trolley System

❐ ❐ ❐ ❐
(MTS)

❐ ❐ ❐ ❐
3D Ceiling Stand

❐ ❐ ❐ ❐
Unit

❐ ❐ ❐ ❐
Unit/Stand (2nd Plane)

❐ ❐ ❐ ❐
Patient Table

❐ ❐ ❐ ❐
Bucky Exposure Table
Electronics Cabinets ❐ ❐ ❐ ❐

Computer Cabinet ❐ ❐ ❐ ❐

Cooling Unit ❐ ❐ ❐ ❐

Consoles ❐ ❐ ❐ ❐

Tableside Control Unit ❐ ❐ ❐ ❐

Monitors ❐ ❐ ❐ ❐

Video Recorder ❐ ❐ ❐ ❐

Hardcopy/Printer ❐ ❐ ❐ ❐

1. Safety-relevant installation work steps; absolutely observe next paragraph!

1
The system was installation according to the following installation instructions; all

AX Systems AX00-000.813.01.03.02 Page 4 of 6 Siemens

05.08 AX SCM
Installation Certificate 5

safety-relevant work steps were performed according to the applicable and enclosed instal-
lation instructions:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

If "no" is checked, give reason:

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

________________ ________________________ ______________________

Location, Date Responsible Installer Responsible Project Man-
ager

_________________________ ______________________
Name in block letters Name in block letters

If there is a country-specific certificate that covers the same topic, it may also be used.

Work steps that were also performed:

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Please make absolutely certain to return the cer-

tificate to:
Siemens Medical Solutions Fax +49 (9191) 18-13 8888
AX SCM
Siemensstrasse 1
91301 Forchheim
Germany
e-mail: AX-Installation-Feedback@siemens.com

Siemens AX00-000.813.01.03.02 Page 5 of 6 AX Systems

05.08 AX SCM
6 Installation Certificate

AX Systems AX00-000.813.01.03.02 Page 6 of 6 Siemens

05.08 AX SCM