TERRITORY
*
NORTHEAST
SOUTHWEST - ASSURED
WESTCOAST - ALINEA
WESTCOAST - SHIN
WEST COAST – Centrelake
OTHER
LOCATION SW
*
Arizona Mobile
California Mobile
Clovis Fixed
Georgia Mobile
JPS Mobile
La Cholla Fixed
Las Cruces Fixed
Los Lunas Fixed
New Mexico Mobile
Scottsdale Fixed
Texas Mobile
Washington Mobile
LOCATION NE
*
CIA
FLI
VIK
IAH
NRI
HVI - NW
HVI - MR
CPI
MD-Poug
MD-Wall
SMI - POTTSVILLE
SMI - ALLENTOWN
ALI
CNY EAST
CNY HILL
CNY CLAY
SRA
SRAOP
Premier
LOCATION WC
*
Pomona - Fixed
Santa Ana - Fixed
MM East
SHIN - BP
SHIN - LA
SHIN - FULLETRON
MM West
Mobile US
Kaiser
LOCATION WC SHIN
*
SHIN - LA
SHIN - BP
SHIN - FULLETRON
West coast Centerlake
Please Select
Anaheim
Chino
Covina
Downey
El Monte
Hemet
Ontario
Pomona
Upland
West Covina
Westwood
VIC – West Covina
VIC – Anaheim
VIC - Downey
LOCATION OTHER
*
STATE
*
PA
NM
NY
NJ
AZ
CA
GA
TX
WA
Other
TYPE
*
FIXED SITE
PORTABLE
TRAILER
COACH
Other
MODALITY
*
CT
X-RAY
MRI
PET/CT
NUC MED
OPEN MRI
IR / BX
ULTRASOUND
MAMMO
FLUOROSCOPY
ENTIRE COACH
DEXA
ECHO
Other
UNIT ID
ALINEA
MME12
MME14
MME15
MME18
MME19
MMW19
MMW24
MMW25
MMW26
MMW27
MMW28
MMW29
MMW30
MMW31
MMW32
POMONA MAMMO
POMONA US
POMONA XRAY
SA US
US A
US B
VAN 1
VAN 2
VAN 3
VAN 4
VAN 6
VAN 7
VAN 8
VAN 9
VAN 10
VAN 11
VAN 12
VAN 13
SCION
RAV
COACH A
COACH C
COACH D
COACH E
COACH F
ASSURED
AL AKA 1650
AZ 7 9856
AZ 8 1248
AZ 9 1830
AZ 16 8336
AZ 17 2400
AZ 19 4290
AZ 20 4291
AZ 21 4586
AZ 26 2100
AZ 27 1981
AZ 28 8006
AZ 34 1248
AZ 35 2400
AZ 38 2100
AZ AKA 1650
AZ In house In house
CA 1 420
CA 6 3674
CA 7 4291
CA 11 420
CA 12 4290
CA 20 4291
CA 28 8006
CA AKA 1650
ID 8 582
IL AKA 1650
IN AKA 1650
LA AKA 1650
MI AKA 1650
NC AKA 1650
NE AKA 1650
NJ AKA 1650
NM 17 2400
NM 19 4290
NM 20 4291
NM 21 4586
NM 27 1981
NM 28 8006
NM 34 1248
NM 35 2400
NM 37 2100
NM In house In house
SC AKA 1650
TN AKA 1650
TX 1 2100
TX 1JPS 9007
TX 3 1412
TX 6 AKA 1650
TX 17 2400
TX 19 4290
TX 27 1981
WA 6 3950
WA 7 3714
WA 8 582
WA 9 3950
WA 10 3776
WA Steck Unit 2107
Other
Alinea and Assured only*
MAKE / MODEL
Ex: 1.5, 3T, 16 Slice, Oasis
MANUFACTURER
*
Siemens
Phillips
Hitachi
Fuji
GE
Other
DATE IT WENT DOWN
*
-
Month
-
Day
Year
Date
TIME
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
DATE WHEN IT WAS FIXED
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
NUMBER OF DAYS IT WAS DOWN
IF MACHINE ISN'T FIXED YET, IS SERVICE ON THE WAY/SCHEDULED?
YES
NO
NEED APPROVAL / ASSISTANCE
REASON IT WENT DOWN
*
TOTAL COST (Write "SC" if it was covered under contract)
*
DID ALL PATIENTS GET RESCHEDULED?
*
YES
NO
Other
SERVICE COMPANY
*
Siemens
Phillips
Hitachi
Fuji
GE
626
SIGMA
Assured
NE
Alinea
Other
SERVICE REP
COMMENTS ON SERVICE / SITUATION
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Heather Leone
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