DA Form 5621-R Medical Equipment Electrical Safety

DA Form 5621-R - also known as the "Medical Equipment Electrical Safety" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5621-R - was last revised on May 1, 2006. Download an up-to-date fillable PDF version of the DA 5621-R down below or look it up on the Army Publishing Directorate website.

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MEDICAL EQUIPMENT ELECTRICAL SAFETY
For use of this form, see TB 38-750-2; the proponent agency is OTSG.
HOSPITAL/AREA/LOCATION:
END ITEM NOMENCLATURE:
MFR:
MDL:
SERIAL:
ECN:
TYPE OF EQUIPMENT: (Check One)
PORTABLE (P)
FIXED (F)
TEST I - GROUNDED RESISTANCE
P = 0.50 OHM
REMARKS:
Test Equipment
(TMDE)
}
H
N
G
TEST II - CHASSIS LEACKAGE CURRENT
GROUNDED
GROUND OPEN
H
ON
OFF
ON
OFF
N
P = N/A
F = 40Mv/500Mv
P = 300uA
F =5mA
G
PATIENT LEAD INPUT: (Check One - Applies to Tests III, IV, & V)
ISOLATED (I)
NONISOLATED (N)
.
TEST III - LEAD TO GROUND
I = 10uA
I = 50uA
. . .
H
RA
. .
LA
I =
N
N/A
N/A
RL
G
LL
.
C
. .
I = 100uA
I = 100uA
.
H
. .
N =
N
N/A
N/A
G
.
TEST IV - BETWEEN LEADS
I = 10uA
I & N = 50uA
N = 50uA
.
H
RA
RA-RL
N/A
N/A
.
N
RL
LA-RL
G
LA
RA-RL
I = 50uA
TEST V - ISOLATION TEST
.
RA
. . .
LA
H
N/A
N/A
. .
RL
I =
N
LL
G
C
TESTED BY: (Print or Type)
GRADE/RANK:
DATE TESTED (YYYYMMDD)
WORK ORDER #:
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
DA FORM 5621-R, MAY 2006
APD LC v1.00
MEDICAL EQUIPMENT ELECTRICAL SAFETY
For use of this form, see TB 38-750-2; the proponent agency is OTSG.
HOSPITAL/AREA/LOCATION:
END ITEM NOMENCLATURE:
MFR:
MDL:
SERIAL:
ECN:
TYPE OF EQUIPMENT: (Check One)
PORTABLE (P)
FIXED (F)
TEST I - GROUNDED RESISTANCE
P = 0.50 OHM
REMARKS:
Test Equipment
(TMDE)
}
H
N
G
TEST II - CHASSIS LEACKAGE CURRENT
GROUNDED
GROUND OPEN
H
ON
OFF
ON
OFF
N
P = N/A
F = 40Mv/500Mv
P = 300uA
F =5mA
G
PATIENT LEAD INPUT: (Check One - Applies to Tests III, IV, & V)
ISOLATED (I)
NONISOLATED (N)
.
TEST III - LEAD TO GROUND
I = 10uA
I = 50uA
. . .
H
RA
. .
LA
I =
N
N/A
N/A
RL
G
LL
.
C
. .
I = 100uA
I = 100uA
.
H
. .
N =
N
N/A
N/A
G
.
TEST IV - BETWEEN LEADS
I = 10uA
I & N = 50uA
N = 50uA
.
H
RA
RA-RL
N/A
N/A
.
N
RL
LA-RL
G
LA
RA-RL
I = 50uA
TEST V - ISOLATION TEST
.
RA
. . .
LA
H
N/A
N/A
. .
RL
I =
N
LL
G
C
TESTED BY: (Print or Type)
GRADE/RANK:
DATE TESTED (YYYYMMDD)
WORK ORDER #:
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
DA FORM 5621-R, MAY 2006
APD LC v1.00
INSTRUCTIONS FOR COMPLETING DA FORM 5621-R
GENERAL
HOSPITAL/AREA/LOCATION: Identify the owning medical treatment facility and location of the end item within the
facility, i.e. Brooke Army Medical Center, Main OR, Room 3.
END ITEM NOMENCLATURE: Generic nomenclature for the end item.
MFR: The manufacturer of the end item.
MDL: The model number of the end item. Use the manufacturer's generic model identification rather than a catalog
number.
SERIAL #: The serial number of the end item. If a component of the end item fails the performance test, indicate the
components serial number in the REMARKS block.
ECN: Equipment Control Number or locally assigned index number.
TYPE OF EQUIPMENT: Check the appropriate block. Patient lead input refers to the way in which the patient
connected leads are electrically connected to the equipment.
TESTED BY/DATE TESTED: Legibly print or type this information.
WORK ORDER #: The control number assigned to the work order initiated to correct the equipment safety failures
identified during the performance test.
PERFORMANCE TESTING
The values indicated on this form are IAW NFPA 99, and indicate the maximum acceptable limits for each test and
tested type of equipment. Additional instructions can be found in NFPA 99, Chapter 8.
ABBREVIATIONS: (Perform only those tests required by the appropriate type of equipment being tested. Refer to
the abbreviations below.)
P - Portable Equipment.
I - Portable Equipment with Isolated Patient Connected Leads.
N - Portable Equipment with Nonisolated Patient Connected Leads.
F - Fixed Equipment.
PORTABLE EQUIPMENT W/O PATIENT CONNECTED LEADS.
Perform TEST I & II only. *
PORTABLE EQUIPMENT W/ PATIENT CONNECTED LEADS.
Perform TEST I thru V. * (Test III & V - the number of lead tests will depend on the type of equipment being tested
i.e., 12 lead vs. 3 lead equipment. Use the REMARKS block if additional space is required to document the results.
FIXED EQUIPMENT.
Perform TEST I & TEST II - GROUND LIFTED during initial installation.
After initial installation periodically only perform Test II - GROUNDED (Critical Care Areas - 40mV; General Care
Areas - 500mV).
* TEST II - GROUND LIFTED MAXIMUM LIMIT EXCEPTIONS:
Exception 1 - 250mA maximum acceptable limit when equipment is individually scheduled by serial number or index
number for periodic testing.
Exception 2 - 500mA maximum acceptable limit when the equipment is special purpose; safety testing will be
performed quarterly.
Page 2 of 2
DA FORM 5621-R, MAY 2006
APD LC v1.00

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