DA Form 5624-R at a glance
What it is: This is the DC Defibrillator Inspection Record.
Who signs: INSPECTED BY: Name of the technician performing the test. SIGNATURE: Signature of the technician performing the test.
A filled-in DA Form 5624-R example: a technician certifies a defibrillator
How to fill out DA Form 5624-R, box by box
Hospital/Area/Location, MFR, MDL, SERIAL and ECN
HOSPITAL/AREA/LOCATION: Self explanatory.
MFR: Name of manufacturer.
MDL: Use the manufacturer's generic model identification rather than a catalog number.
SERIAL: The serial number of the defibrillator.
ECN box: Equipment Control Number or locally assigned index number.
Visual inspection (items 1 thru 5)
Note on visual inspection (Items 1 thru 5) and performance tests: performance test will be made after the batteries have been serviced.
PASS: Visually inspect each of the listed areas and indicate whether they pass with no required action. Enter either YES (Y) or NO (N).
DESCRIPTION OF ACTION NEEDED: Briefly indicate what action is required e.g., replace paddle plates, replace line cord.
DATE ACTION COMPLETED: The date a maintenance work order was completed.
Output energy, control settings, energy delivered, previous value and change
6. OUTPUT ENERGY. CONTROL SETTINGS: Indicate the output energy settings available through operator control settings.
If more settings are available than space provided, use an equal sampling of low, medium, and high settings.
ENERGY DELIVERED: Indicate the actual delivered energy when measured with calibrated TMDE.
PREVIOUS VALUE: Indicate the "ENERGY DELIVERED" values from the previously filed performance test.
CHANGE: Subtract the "ENERGY DELIVERED" from the "PREVIOUS VALUE." The result can be a negative number.
Charge time, internal discharge function, synchronized operation and other features
7. CHARGE TIME: The time it takes to charge to the maximum energy setting.
7. PREVIOUS VALUE: Taken from the previously filed performance test.
8. INTERNAL DISCHARGE FUNCTION: Self explanatory. 9. ENERGY DELIVERED AFTER 1 MINUTE: Self explanatory. 10. TENTH REPEATED DISCHARGE: Self explanatory. 11. SYNCHRONIZED OPERATION: Self explanatory.
12. OTHER FEATURES: Test other special features.
Certification, date inspected, inspected by and signature
Check one of the boxes: Full Certification with label attached, or Provisional Certification with a work order #.
Full Certification: Unit meets all the manufacturer's specifications.
Provisional Certification: Unit may remain in use and can be used safely but repairs are required (a work order is required when this block is checked).
DATE INSPECTED: The date a maintenance work order was completed.
NEXT INSPECTION DUE: Self explanatory.
INSPECTED BY: Name of the technician performing the test.
SIGNATURE: Signature of the technician performing the test.
More rules for DA Form 5624-R
For use of this form, see TB 38-750-2; the proponent agency is OTSG.
Sources
[1] DA Form 5624-R (MAY 2006), DC Defibrillator Inspection Record, U.S. Army (the Official source link on this page).