Free 3071 - Federal

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION

GENERAL INFORMATION FIELD TEST RECORD
(Use Form FDA 2782, Field Test Record Continuation if more space is needed)

Print Legibly. Use Black Ball Point Pen. Enter one character per box.

FIELD TEST SERIAL NO. (1-8)

GI
REGIONAL REVIEW (NAME)

Card No. (9-10)

Facility Identification Name (11-80) Street Address (11-80)

01 02

City (11-73)

State Code
74 75

Zip Code
76 80 81 84

03
Room Number (11-37)

04
Surveyor Information

Person Interviewed (38-56)

Telephone Number
57 59 60 66

Name (Last, First, Middle Initial) (11-67)

Accomp. Agency
68 69

Accomp. District
70 72

05

Signature

FDA Region
73 74 75

Date (Mo/Day/Yr)
82

Survey Information Purpose of Survey I -- Initial Survey R -- Resurvey Assembler Report Nos. (Letter included)
12 18 19 25 26 32

C -- Compliance F/U A -- Audit

H -- HIA
11

Installation Date
33

Mo/Day/Yr
40

Previous FTRs (5 or 6 digit numbers)

41

46

47

52

System Information Certification Status C -- System Fully Certified M -- Mixed Certified/Non-Certified Control Serial No.
52 63

V -- Fully Certified With Variance N -- Fully Non-Certified Date of Mfr. (Mo/Yr)
M M Y Y Y Y 57

06

Control Manufacturer

Control Model No.

Mfr Code
68 71

Unique ID
72 77

System Maintenance Is a maintenance schedule designed for compliance being followed? Is the maintenance schedule available for review?
79

Y -- Yes
78

N -- No X -- Unknown

Who does the compliance maintenance? M -- Mfr Rep P -- Private I -- In House N -- Not Done X -- Unknown
80

Instrumentation MDH Serial No.
11 14

Light Meter Serial No.
15 22

Number of Each Form Attached

Assembler Data

06

AR
19 20

DR
21

CF HN
24

Company

AF
22 23

MA KV
26 27

Street Address

City

State

Zip Code

UF
25

CT
Home District FEI Number
31 33 34 43
EF

MR
28 29

VC
30

FORM FDA 3071 (4/01)

spacer assembly (out of beam)

spacer assembly (in beam) BRH test stand

beam defining assembly

6-cm3 ion chamber (side view)

image intensifier and spot-film device

Al filters

0.1 inch Cu

focal spot assembly

.
10 9 8 7

MDH electrometer (front view) and 6-cm3 ion chamber

slide assembly (grid down) with plastic cassette

1/8 inch PB

test stand (BENT)

6 5 4

cardboard support (BENT)

3

2

1 9

2 1 3 4

TV view (slide assembly grid)

8 7 6 5 4

3

2

FORM FDA 3071 (BACK) (4/01)
1