Sign-Off List

Sign-Off List

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: