SA INSTRUMENTATION ________________________________________________________________________________________ FONE/FAX/TAD 858.453.1776 OUTSIDE CALIFORNIA 800.266.1776 BIOAMP RFQ/ORDER FORM This form must be completed or your order cannot be entered ________________________________________________________________________________________ ORGANIZATION: DATE: ADDRESS: SPECS APPROVED BY: SIGNED: PHONE: FAX: ________________________________________________________________________________________ CHECK APPLICABLE BOXES AND/OR SUPPLY DETAILS: ($) Denotes EXTRA COST OPTIONS 1. Concept: This bioamp is primarily an EEG____; EMG____; or a UNIVERSAL____ system. The total number of channels is:______. 2. Mechanical: Tabletop____; Tripod/Tabletop ($)____; 19" Rack mount ($)____. The front panel electrode monitors (leds) show a number sequence____ (channel #); or electrode designators____; Detail:(use separate sheet if necessary)______________________ . 3. Input: ELECTRO-CAP (monopolar)____; supply an E-CAP ($)____(send details including E-CAP cable length). SAI prefers to supply the initial E-CAP to insure proper connection with the BIOAMP or we can adapt yours. An E-CAP can be connected direct to the BIOAMP or via an input HEADBOX. &/or Simple HEADBOX for bipolar electrode connections into 0.08" jacks ($)___; also require an require an E-CAP sub-D input ($)____. &/or A multifunctional HEADBOX ($)____for monopolar/bipolar loose-leads and E-CAP; includes switches for grounding-out unused inputs, a switchable REF buss and two cal signals. Built in digital IMPEDANCE METER ($)____. HEADBOX MOUNT: Table ____; or Tripod/Table ($)____; or Wall/Table ($)____. HEADBOX CABLE: HEADBOX to BIOAMP ______ft. 4. THE FIXED GAIN IS:________. For SNR select a gain which at maximum signal input levels, produce an output that is ~80-90% of the maximum input level allowed by your ADC-DSP or other input device. Note that the maximum bioamp output is +/_2.4V (4.8Vpp). THE FIXED BANDPASS IS:________to________ Hz (Frequency Hz = 0.159/Tc sec) Four-pole LPF ($)____; (standard is 2-pole Butterworth). -OR- IF ADJUSTABLE PARAMETERS ARE REQUIRED 5. BASE QUAD OPTION:____($) One or more or all channels are set by a by a three switch set (GAIN/HPF/LPF) of four positions switches. DC response ($)____; (uses one position of the QUAD OPTION HPF) Four-pole LPF ($)____; (standard is 2-pole Butterworth) Again, when selecting gains, take into consideration the maximum BIOAMP output of +/-2.4V (4.8Vpp) 6. SECONDARY QUAD OPTION:____($) Additionally, any number of individually controlled channels is available. A typical BIOAMP configuration is, each of the last 2-4 channels are on separate three switch sets of controls; the remainder are controlled by a single three switch set. Sepecify your exact channel configuration including the four GAIN/HPF/LPF points desired on each (a diagram may be helpful): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 7. CALIBRATOR SIGNAL LEVELS: (Note that two cal signals, one frequency and one waveform are standard features and are required during manufacture for testing and calibration. Optionally you may select an additional cal signal waveform and frequency.) a) Primary Calibrator _____uVpp & ____uVpp; ____freq _____Hz (16 hz std) sine____or square___. b) Secondary Calibrator ($) ____freq _____Hz (16 hz std) sine____or square___. OPTIONAL ($)____; An additional calibration signal; a pulse with an amplitude of ______ uVpk, with a pulse width of _____ ms; and when free-running, at repetition rate of one pulse /______ sec. A pulse is commanded by front panel push-button; and remotely from a TTL command back thru the output cable requires two lines: (COMMAND & COMMON). All calibrator signals are available from jacks on the bioamp and the optional multifunctional headbox. 8. BATTERY: Time required before battery change out ______ hrs. (~20 hrs std) 9. OUTPUT CABLE: STRIP CABLE to: fan-out loose wires. Length:___ft. STRIP CABLE to: a BNC breakout box. Length:___ft. STRIP CABLE to: ADC-DSP; send specs. Length:___ft. STRIP CABLE to: other; send specs. Length:___ft. NOTE: The SAI bioamp has a fixed output pin configuration using 25-pin sub-D connectors. Adaptive output cables are then supplied terminating into various connectors or loose-wires. If SAI receives detailed pin-out information for interfacing into your ADC/DSP, a cable can be supplied connecting or output directly into your processing device. You must also specify the pins for remote TTL STATUS FLAG output and its common plus any additional pins for remote TTL commands and their common (e.g. an optional CAL PULSE). This info can be sent at a later date if desired; however if timely and detailed information is not forthcoming, SAI cannot supply this cable with your system. 10. Other options ($): Remote controls, TTL flags, QRS blanking (EMG), SCL, SCR, GSR, TEMP, RESP, ect. SPECIFY:_______________________________________ 11. Additional channels: Do you intend to eventually increase the number of channels in this system? _____; if so, to how many channels:______. NOTE: We cannot quote or enter orders without this completed form. We must know precisely your requirements to minimize errors.