FONAR Field Service Report (5503020-01 Rev C)

1. Site & Service Identification * Indicates required field

Site # * 3 or 4 digits (e.g. 222)

Site Name * (Auto-filled from Site #)

Report Date * Date of service report

Service # * Integer > 0 (e.g. 22222)

Cust. P.O. # Optional / if applicable

UDI (Unique Device Identifier)

UDI not applicable (installation before 2025)

2. Service Representatives

Representative 1 (Lead Engineer) *

Representative 2 (Assisting Engineer)

3. Labor Expense Summary

Record travel and on-site labor hours for up to 5 entries. Rep. # must be 1 or 2 when a date is entered.

Row	Rep. #	Date	Travel Time (h) 1/4 hr (0.25) steps	Labor Start 15-min intervals	Labor End 15-min intervals
1
2
3
4
5

ℹ️ Rules: Rep. # (1 or 2) requires the corresponding Representative name in Section 2 above and is required whenever a date is entered. Travel time must be in 1/4 hr (0.25) increments. Start and End times must be in 15-minute intervals (:00, :15, :30, :45).

4. Problem Description *

Minimum 10 characters required detailing reported symptoms or reason for visit.

5. Work Performed

Select all categories of work that apply to this service visit:

Repaired part(s) — Section A becomes mandatory (min. 10 chars)

Replaced part(s) — Section B becomes mandatory (all 3 fields required)

General Maintenance Activities — Section A becomes mandatory (min. 10 chars)

A. Description of Repair or General Maintenance Activities

Optional unless Repaired part(s) or General Maintenance Activities is checked.

B. Description of Replaced Part(s) and Serial Number (if applicable)

Part Name

Removed Part S/N

Installed Part S/N

C. Test and Inspection Data *

Test Run * (Select either ACR T1 or Other):

ACR T1 Other, namely...

Results *:

D. Conclusion and System Status *

System Scanning Operational — Scanner verified operational and returned to clinical service

Follow-up Service Required:

Follow-up Service Details (if applicable)

Technician PIN * (Saved on device) Authorized team PIN required for submission.

Field Service Representative Certification & Signature *

Draw your signature below using touch, stylus, or mouse to verify completion of this service report.

Signature will be permanently stamped into field Signature8 of PDF 5503020aRevC.