TomTec QUADRA 4 - Quadra 4 Decontamination Form; Decontamination Form Instructions

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Quadra 4 Operator’s Manual TOMTEC

216

QUADRA 4 DECONTAMINATION FORM

In order to protect personnel involved in the service and repair of instruments, one must ensure

that risk factors hazardous to health (Biological-infectious material or Radioactive isotope) are

removed from the equipment in question.

This form must be signed and accompany the Tomtec instrument when it is returned for service

or repair. If not, the service department may be unable to perform service on the instrument.

Model: ____________________________ Serial Number: ____________________________

Type of Contamination:  Biological

 Radioactive

 None

Method of Decontamination:  Biological

 Radioactive

 Other (Please Specify): ______________________

___________________________________________

NOTE: In all cases, equipment must be emptied of all fluids, prior to returning to Tomtec.

I confirm that the instrument listed above has been submitted to an appropriate process of decontamination at this

facility before being shipped to TOMTEC, INC.

Name of Institution: ________________________________________________________________________

Institution Address: ________________________________________________________________________

Date: Signature:

Print Name:

Title:

TOMTEC INC.

1000 Sherman Avenue Hamden, CT 06514 USA

Phone 203-281-6790 Fax 203-248-5724