Optidew User’s Manual
Michell Instruments 67
APPENDIX E
Appendix E Return Document & Decontamination Declaration
F0121, Issue 2, December 2011
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IMPORTANT NOTE: Please complete this form prior to this instrument, or any components, leaving your
site and being returned to us, or, where applicable, prior to any work being carried out by a Michell
engineer at your site.
Instrument Serial Number
Warranty Repair? YES NO Original PO #
Company Name Contact Name
Address
Telephone # E-mail address
Reason for Return /Description of Fault:
Has this equipment been exposed (internally or externally) to any of the following?
Please circle (YES/NO) as applicable and provide details below
Biohazards YES NO
Biological agents YES NO
Hazardous chemicals YES NO
Radioactive substances YES NO
Other hazards YES NO
Please provide details of any hazardous materials used with this equipment as indicated above (use continuation sheet
if necessary)
Your method of cleaning/decontamination
Has the equipment been cleaned and decontaminated? YES NOT NECESSARY
Michell Instruments will not accept instruments that have been exposed to toxins, radio-activity or bio-hazardous
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Work will not be carried out on any unit that does not have a completed decontamination declaration.
Decontamination Declaration
I declare that the information above is true and complete to the best of my knowledge, and it is safe for Michell
personnel to service or repair the returned instrument.
Name (Print) Position
Signature Date
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