0112-0109 H 299
E
Decontamination Certificate
Procedure for Completing the Certificate
Circle the appropriate statement and complete both pages of the form
as necessary.
1. The instrument or parts that are being returned for rework were
not used for any application involving blood or other potentially
infectious material.
2. The instrument or parts that are being returned for rework have
been decontaminated.
The instrument or parts that are being returned for rework
have NOT been decontaminated. Every effort must be made
to decontaminate before returning instruments or parts to
the factory. Include a statement that identifies the type of
potentially infectious materials involved, e.g., blood or other
body fluids, as well as why no decontamination was
performed:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
This is to certify that this part or instrument has been prepared for
shipment by me or someone under my supervision.
Signature: ________________________________________
Name (Print)_______________________________________
Date _____________________
Part # _________ Model # __________ Serial # _________
Nuclides Used: ____________________________________
Biologicals Used (e.g., human serum, body fluids):
+_______________________________________________________
Customer Contact Name: ____________________________________
Institution: _______________________________________________
Phone # ___________________ Fax # __________________
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