Chiller Replacement Questionnaire

Facility Name
Facility Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Site Contact
First Last
Phone
Email
Target Date
Date Format: MM slash DD slash YYYY
Current System Information
System (MRI, CT, etc.)
Brand
Model
Chiller Brand
Serial
Model
Voltage
Have any changes or upgrades been made to the imaging system? If yes, please provide explanation.
- Yes
- No
Notes
Has the system been relocated or moved from original location? If yes, please provide explanation.
- Yes
- No
Notes
Will the replacement chiller be installed in the same location as the current chiller? If no, please explain.
- Yes
- No
Notes
Does the current system include a separation cabinet (LCC, SEP, HEC)?
- Yes
- No
Notes
Does the existing piping include a city water bypass?
- Yes
- No
Notes
Is the ambient temperature below 113F (45C)?
- Yes
- No
Notes
Is the ambient temperature above -13F (-25C)?
- Yes
- No
Notes
Does this facility require OSHPD pre-certification?
- Yes
- No
Notes
Where is the current chiller located?
- Inside
- Outside
- Rooftop
Please check if the either of the chiller configurations listed applies to the current chiller.
- Water Cooled
- Remote Condenser
What is the approximate horizontal distance between the system and the chiller installation? (ft)
What is the approximate vertical distance between the system and the chiller installation? (ft)
Special Considerations
Name of Project Manager
First Last
Company Name
Phone

Current System Information