Berthold LB 985 - Confirmation on Decontamination

LB 983 NightSHADE Operating Manual Appendix
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10.3 Confirmation on Decontamination
If you return an instrument to BERTHOLD TECHNOLOGIES for servicing purposes which is not
properly decontaminated, there will be a health risk for BERTHOLD TECHNOLOGIES employ-
ees. We therefore need your confirmation that the instrument was decontaminated and cleaned
properly before shipping. If the form below is not filled in accordingly and completely, we are
forced to reject the instrument. Please understand that this is intended to protect our employees
from any hazards.
Please put one copy into the shipping box and a duplicate into an envelope attached to the out-
side.
(Please use capital letters to fill in the form!)
instrument / component:
serial no.:
instrument or component has come into contact with:
[ ] radioactive substances
Isotope(s):
means of decontamination applied:
[ ] chemical reagents
specify:
R and S rules:
means of decontamination applied:
[ ] biological material
specifiy:
means of decontamination applied:
[ ] contagious agents
specify:
means of decontamination applied:
indicate security level of the laboratory the instrument has been used in
[ ] S1 [ ] S2 [ ] S3 [ ] S4
[ ] I hereby confirm that the instrument or component specified above was not
contaminated with any of the above mentioned substances / reagents / agents
[ ] I hereby confirm that the instrument or component specified above was
decontaminated / cleansed using the appropriate method
date:
signature:
name:
title:
phone:
fax:
address:
7-40.12 – 31531/03