GE Services
Health & Safety Declaration Form
for Product Return or Servicing
DOC1149544
To ensure the mutual protection and safety of GE Healthcare personnel, our customers, transportation personnel and our
environment, all equipment must be clean and free of any hazardous contaminants before shipping to GE Healthcare. To avoid
delays in the processing of your equipment, please complete this checklist and include it with your return.
1. Please note that items will NOT be accepted for servicing or return without this form
2. Equipment which is not sufficiently cleaned prior to return to GE Healthcare may lead to delays in servicing the equipment
and could be subject to additional charges
3. Visible contamination will be assumed hazardous and additional cleaning and decontamination charges will be applied
Equipment type / Product No: Serial No:
I hereby confirm that the equipment specified above has been cleaned to remove any hazardous substances and that the area
has been made safe and accessible.
Name in Capital letters:
Company or institution:
Position or job title: Date (Year/month/date): 200000/00000/00000
GE, imagination at work and GE monogram are trademarks of General Electric Company.
GE Healthcare Bio-Sciences Corp, 800 Centennial Avenue, P.O. Box 1327, Piscataway,
NJ 08855-1327, USA.
© 2010-12 General Electric Company—All rights reserved. First published April 2010.
28-9800-27 AB 05/2012
Return authorization number: and/or Service Ticket/Request:
To receive a return authorization number or service
number, please call local technical support or
customer service.
Please specify if the equipment has been in contact with any of the following:
Yes
No Radioactivity (please specify):
Yes No Infectious or hazardous biological substances (please specify)
Yes
No Other Hazardous Chemicals (please specify)
Equipment must be decontaminated prior to service / return. Please provide a telephone number where GE Healthcare can
contact you for additional information concerning the system / equipment.
Telephone No:
Liquid and/or gas in equipment is: Water Ethanol None, empty Argon, Helium, Nitrogen
Liquid Nitrogen Other, please specify:
Signed:
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