Completion Sign Off- Legacy Install

Location__________________________________

Installation Team___________________________

Date of Install___________________________

***PLEASE LIST EQUIPMENT INSTALLED NEXT TO EACH LINE ITEM***

Pretest 

❑Lensometer interfaced and tested

Vision diagnostic instrument name:

❑Autorefractor/Keratometer interfaced and tested

Vision diagnostic instrument name:

❑NCT interfaced and tested

Vision diagnostic instrument name:

❑Ancillary test camera interfaced and tested (Neck in a straight upright position)

Type of logitech:

❑Video Slit Lamp interfaced and tested

Vision diagnostic instrument name:

❑Retinal Imaging Device interfaced and tested

Vision diagnostic instrument name:

❑Fundus camera interfaced and tested

Vision diagnostic instrument name:

Visual Field interfaced and tested

Vision diagnostic instrument name:

❑Start up Admin password attached to the bottom of the keyboard

Password:

❑Pretest monitor sound level checked & functional

❑Additional vision diagnostic equipment names: instruments interfaced & tested___________,_________

Exam Lane 1

❑Acuity chart tested

Vision diagnostic equipment name:

❑Phoropter Arm height verified/ set high (it is typically installed incorrectly at low level)

Vision diagnostic instrument name:

❑Startup Admin password attached to the bottom of the keyboard

Password:

❑Exam camera interfaced and tested  (Camera setting is correct)

Type of Logitech:

❑The Passthrough tested

❑Reading card light functioning

❑The printer tested/ leave a printed copy (on printer)

❑Exam lane monitor sound level checked

❑Video Slit Lamp interfaced and tested (if applicable)

Exam Lane 2 if applicable

❑Acuity chart tested

Vision diagnostic equipment name:

❑Phoropter Arm height verified/ set high (it is typically installed incorrectly at low level)

Vision diagnostic instrument name:

❑Startup Admin password attached to the bottom of the keyboard

Password:

❑Exam camera interfaced and tested  (Camera setting is correct)

Type of Logitech:

❑The Passthrough tested

❑Reading card light functioning

❑The printer tested/ leave a printed copy (on printer)

❑Exam lane monitor sound level checked

❑Video Slit Lamp interfaced and tested (if applicable)

Interfacing Equipment List

If applicable.

❑Test EMR import and export.

Remote Technician used for live session:

Follow-Up Items

❑Open Items requiring a follow-up:

PreTest Close-Out Captures Installer Initials

Full Room Capture (multiple captures if necessary)

Table with Interfaced Instruments

Cabling underneath table ran from test instruments to jacks

Cabling ran from ports to back of cabinet

Cabinet with door open

TV mounted on wall with Logitech in correct position

Cabling behind TV (Full view of ports w/ cabling ran)

Any Raceway Installed

Capture all ports at wall in correct positions with labeling

All Exam Lane Picture Captures Installer Initials 

TV screen of all devices integrated with DO Machine Interface

Capture all ports at wall in correct positions with labeling 

Exam chair and stand

Phoropter height correct position

Cabling ran from ports to back of cabinet

Cabinet with door open

Tv mounted on wall with Logitech in correct position

Cabling behind TV (Full view of ports w/cabling ran)

Acuity Chart

Printer tested/ leave a printed copy

Any Raceway Installed (if applicable)

Mirror hung (if applicable)

Arrival time and completion:

This confirms the completion of this install with the signature: