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Equipment Information
	Brand:
	Model:
	Year of Manufacture:
	Serial #:
	For Linear Accelerators:
	Photon Energy: Single Dual
	Low Energy Photon:	MV
	High Energy Photon:	MV
	Electrons:	MeV
	Couch Type:
	Beamstopper Counterweight
	Digital Console Analog Console
	Software Version:
	Dynamic Wedge? Yes No
	Wedge Sizes:
	Elec. Cone Sizes:
	Independent Jaws Single Dual
	Accessory Type I II III
	Multileaf Collimator
	# of leaves:
	Model Type:
	MLC Brand:
	MLC Model:
	Shaper Digitizer W/S Computer
	W/S Software
	IMRT, Auto Field Seq, etc:

Please Enter Age of Components:
	Magnetron	Years Months
	Thyratron	Years Months
	Klystron	Years Months
	Waveguide	Years Months
	Electron Gun	Years Months
	RF Driver	Years Months
	Beam Hours:
	Filament Hours:


	List any other major components that may have been replaced. with dates:


	Has this unit ever been refurbished? If yes, when and by whom?:

	Does the system include:
	Room Lasers?	Yes No
	Manuals?	Yes No
	Spare Parts Kit?	Yes No
	Base Frame?	Yes No

Unit Availability
	Is Unit Still in Service? Yes No
	If yes, date unit available for deinstallation?
	/ /
	If no, how long has unit been out of service?
	Vacuum still on waveguide? Yes No
	Date by which equipment must be removed:
	/ /


	Other Enquiries: