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Alco-Sensor Iv With Printer Maintenance Report

This document is a maintenance report form for an ALCO-SENSOR IV breathalyzer. It contains checklists to test components like the digital readout, temperature, printer, and time/date display. Standards for breath alcohol accuracy are also listed, including acceptable ranges for simulator solution and compressed ethanol gas mixture tests. Technicians must record the number of breath tests in various blood alcohol concentration ranges since the last maintenance and note any repairs made to restore proper functioning.

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Kevon Small
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161 views1 page

Alco-Sensor Iv With Printer Maintenance Report

This document is a maintenance report form for an ALCO-SENSOR IV breathalyzer. It contains checklists to test components like the digital readout, temperature, printer, and time/date display. Standards for breath alcohol accuracy are also listed, including acceptable ranges for simulator solution and compressed ethanol gas mixture tests. Technicians must record the number of breath tests in various blood alcohol concentration ranges since the last maintenance and note any repairs made to restore proper functioning.

Uploaded by

Kevon Small
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES Save Print Reset

STATE PUBLIC HEALTH LABORATORY


ALCO-SENSOR IV WITH PRINTER MAINTENANCE REPORT REPORT #7

Complete this report in duplicate at the time of the regular monthly preventative maintenance check, and whenever instrument is repaired.
Send copy to Department of Health and Senior Services; retain original in department file.
ALCO SENSOR IV SN PRINTER SN DATE OF INSPECTION

LOCATION OF INSTRUMENT (STREET AND CITY) TIME OF INSPECTION

CHECKLIST: Place a mark in the box by each item if found to be satisfactory or if operating within established limits. (Write in observed val­
ues where determined.) Unmarked items must be corrected before using instrument.

DIGITAL READOUT (ALL ELEMENTS OPERATIONAL)

TEMPERATURE OF ALCO SENSOR (10°C - 40°C)

PRINTER WORKING PROPERLY

TIME AND DATE DISPLAYING PROPERLY


BREATH ALCOHOL ACCURACY STANDARDS

SIMULATOR SOLUTION COMPRESSED ETHANOL-GAS MIXTURE

STANDARD SUPPLIER ______________________________ LOT # _______________ EXP. DATE ________________

SIMULATOR TEMPERATURE (34°C ± 0.2°C) __________ SIMULATOR SN _____________ SIMULATOR EXP DATE ____________

CALIBRATION CHECK – (ONLY ONE STANDARD IS TO BE USED PER MAINTENANCE REPORT)


Run three tests using a standard solution. All three tests must be within ±5% of the standard value and must have a spread of .005 or
less. Check the box corresponding to the standard solution being used. (PRINTOUT ATTACHED)
0.100% STANDARD - MUST READ BETWEEN 0.095% and 0.105% INCLUSIVE
0.080% STANDARD - MUST READ BETWEEN 0.076% and 0.084% INCLUSIVE
0.040% STANDARD - MUST READ BETWEEN 0.038% and 0.042% INCLUSIVE

TEST 1 ☛ TEST 2 ☛ TEST 3 ☛

RFI DETECTOR OPERATING

INDICATE THE NUMBER OF BREATH TESTS IN THE FOLLOWING RANGES SINCE THE LAST MAINTENANCE REPORT:
(DO NOT INCLUDE SELF-ADMINISTERED TESTS)

REFUSALS (0-.04) (.05-.09) (.10-.14) (.15-.19) (OVER .19)


List any new parts and describe any alteration or modification that was made to restore the instrument to operate satisfactorily and within
established limits (use other side if necessary).

INSPECTING OFFICER
SIGNATURE PRINT NAME

�
TYPE II PERMIT NUMBER/EXPIRATION DATE TELEPHONE NUMBER

Return completed report to the: Breath Alcohol Program, MO Department of Health and Senior Services, Southeast District Office
2875 James Boulevard
Poplar Bluff, MO 63901
MO 580-1351 (6-10) AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER LAB-114
services provided on a nondiscriminatory basis

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