Rely-A-Care App

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Power & Function

Unit powers on No error lights/alarms Flow meter smooth Oxygen output present Noise level normal

Performance

O2 purity test done

PURITY %

FLOW (LPM)

Pass >= 87%?

Yes No

Physical Condition

Exterior clean No cracks or damage Power cord intact Handle / wheels secure Labels / Serial # intact Intake filter present

OVERALL CONDITION

Clean Dirty Missing

Unit Details

COMPANY

MODEL

LITER FLOW

SERIAL # (Required)

HOUR METER

Decision

Ready for reissue Needs cleaning Needs repair Pull from service

Sign Off

CHECKED BY

SIGNATURE