CERTIFICATE OF INSTALLATION

This is cerify, that the Hospital / Institution accepted the following equipment confirmation yhe
completion of installation :

EQUIPMENT :
No
.
1.
2.
3.
4.
5.
6.
7.

DESCRIPTION

Model

Serial No.

VENTILATOR
BUBLE CPOP
PASIEN MONITOR
PASIEN MONITOR
PASIEN MONITOR
PASIEN MONITOR
KOMPRESOR

MEK MV 2000 SUH 2

HOSTEC
ZONCARE 7000C
ZONCARE 7000C
ZONCARE 7000C
ZONCARE 7000C
VA 04

MV 2000 NA I EO 150
150871022/1408030006
JH051500084 V3 CCE
JH051500540 V3 CCE
JH051500545 V3 CCE
JH051500543 V3 CCE
THC 13131
THC 13129

Has been installed on,

Hospital / institution : RSIA. PERMATA BUNDA
Address

: JL. BRIGJEND KATAMSO No.7 KETAPANG (KAL-BAR)

Phone

Date of Installation

: 15 NOVEMBER 2015

Duration of Warranty : 12 month from thr date of installation.

Hospital / Institution,
Authorised Representative

PT. PERMANA PUTRA MANDIRI

Authorised Representative

SERTIFIKAT KALIBRASI

IDENTITAS ALAT
Nama Alat
Bed Side
Monitor
Bed Side
Monitor
Bed Side
Monitor
Bed Side
Monitor

Merk Pabrik
Zonecare

Tipe
PM-7000C

No. Sertifikat
KSI 15100391

PM-7000C

Nomor seri
JH051500543V3CC
E
JH051500084V3CC
E
JH051500540V3CC3

Zonecare

PM-7000C

Zonecare
Zonecare

PM-7000C

JH051500545V3CC3

KSI 15100389

KSI 15100390
KSI 15100388

IDENTITAS PEMILIK

Nama

: RSIA. PERMATA BUNDA

Alamat

: Jl. Brigjend Katamso No.7 Ketapang Kalimantan Barat

PT. KALMED SEJAHTERA INDONESIA

HASIL KALIBRASI
Nama Order
Nomor Sertifikat
Nama Alat
Merk Pabrik
Tipe
Nomor Seri
Rentang Ukur
Tempat Kalibrasi
Tanggal Kalibrasi

I.

II.

III.

IV.

V.

: A-036
: KSI 15100391
: Bed Side Monitor
: Zonecare
: PM-7000C
: JH051500543V3CCE
:: Ruang Lab Kelistrikan KSI
: 01 Oktober 2015

Kondisi Lingkungan
1. Suhu
2. Kelembaban

: ( 24.50.4 ) C
: ( 53.752.6) %RH

Peralatan Standar Kalibrasi

1. Vital Signs Simulator merk Fluke tipe prosim 4 No. Seri : 2675001
2. SpO2 Functional Tester merk Fluke tipe Spot Light No. Seri : 2675001
3. Thermohygrometer merk Dekko tipe 642 No. Seri : 13004734
4. Electrical Safety Analyzer merk Fluke tipe ESA 612 No. Seri : 2675021
Ketelusuran Peralatan Standar Kalibrasi
1. Vital Signs Simulator
2. SpO2 Functional Tester
3. Themohygrometer
4. Electrical Safety Analyzer

: BPFK Jakarta
: Fluke Biomedical
: PT. Mutuagung Lestari
: BPFK Jakarta

Kondisi Fisik Dan Fungsi Alat

1. Kondisi Fisik
2. Fungsi Alat

: Baik
: Baik

Pengamatan Pengukuran keselamatan Listrik

No
1
2
3
4
5
6
7
8
9

PARAMETER
Main Voltage
Protective Eart Resistance
Insulation Resistance
Earth Leakage Current Normal Polarity
Earth Leakage Current Reverse Polarity
Enclosure Leakage Current Normal Polarity
Enclosure Leakage Current Normal Polarity
No Earth
Enclosure Leakage Current Reservel
Polarity
Enclosure Leakage Current Reservel

AMBANG BATAS

TERUKUR

22010%V
0.2
2 M
500 A
500 A
100 A
500 A

214.2A
0.175
OL M
73.2 A
73.6 A
5.0 A
5.0 A

100 A

5.0 A

500 A

5.0 A

Polarity No Earth

PT. KALMED SEJAHTERA INDONESIA

CALIBRATION OF MEDICAL EQUIPMENT
HASIL KALIBRASI
CALIBRATION RESULT

Parameter

SpO2
(%)

Pembacaan
standar
Standart
Reading
%
70
75
80
85
90
95
97
98
99
100

Nomor Order/ Order Number

: A 036

Nomor Sertifikat/ Certificate Number

: KSI 15100391

Pembacaan alat
Equipment
Reading

Koreksi
Correction

Ketidakpastian
Uncertainty
(U95% K=2)

%
70.3
75.0
80.0
85.0
91.0
95.2
97.5
98.0
99.0
99.0

%
-0.3
0.0
0.0
0.0
-0.1
-0.2
-0.25
-0.0
0.0
1.0

0,5

vii. Kesimpulan / Conclusion

Alat dinyatakan Laiak Pakai
Equipment Stated
(Disampaikan mengikuti PERMENKES No. 363 Menkes/PER/IV/1998
Delivered follow PERMENKES No. 363. Menkes/PER/IV/1998 and
Prosedur Pengujian / Kalibrasi Alat Kesehatan Depatrtemen Kesehatan RI, Tahun 2001)
Prosedure Testing / Calibration of Medical Equipment RI Departement Health, 2001

Viii. Keterangan / Remarks

1. Hasil Ketidakpastian pengukuran mempunyai tingkat kepercayaan 95% dengan faktor
cakupan (K)=2

The result of measurement uncertainty has a confidence level (CL) of 95% with a coverage
factor (K)=2
2. Nilai sebenarnya = Nilai Pembacaan Alat + Nilai Koreksi
True Value = Equipment Reading Value + Correction Value
3. Hasil Kalibrasi tertelusur ke sistemsatuan internasional (SI)
Calibration result are traceable to the international unit system
4. Alat dikalibrasi menurut metode KSI-321, dengan ECRI 410-0595, 454-0595, 425-0595
sebagai standar.
The equipment is calibated according to KSI-312 method, with ECRI 410-0595, 454-0595,
425-0595 as a standard.
Manajer Teknik
Technical Manager

Ahmad Taufik, ST