Name: vacuubrand BVC basic
Brand: vacuubrand
Rating: 4 (1 reviews)

47

Health and safety clearance form

11 Health and safety clearance form

Health and safety clearance form

1. Device (Model): .................................................................................................................................................................

2. Serial no.: ..........................................................................................................................................................................

3. Reason for return / malfunction: ........................................................................................................................................

...........................................................................................................................................................................................

4. Substances (gases, liquids, solids, biological material, e. g. bacteria, viruses) in contact with the device /

which have been pumped:

...........................................................................................................................................................................................

5. Risk level of the used biological material:

☐ 1 ☐ 2* ☐ 3** ☐ 4**

* Contact the VACUUBRAND service absolutely before dispatching the device.

** Devices which have been in contact with biological substances of risk level 3 or 4 cannot be checked, main-

tained or repaired. Also decontaminated devices must not returned to VACUUBRAND due to a residual risk.

6. Radioactive contamination:

☐ yes ☐ no

7. Prior to return to the factory the device has been decontaminated:

☐ yes ☐ no

Description of the decontamination method and the test / verication procedure:

...........................................................................................................................................................................................

8. All parts of the device are free of hazardous, harmful substances:

☐ yes ☐ no

9. Protective measures required for service staff:

...........................................................................................................................................................................................

10. If the paint is damaged, we wish a repaint or a replacement of parts for reason of appearance

(repaint and replacement at customer’s expense):

☐ yes ☐ no

11. Legally binding declaration

We assure for the returned device that all substances, which have been in contact with the device are listed in section

4 and that the information is complete and that we have not withheld any information. We declare that all measures

- where applicable - have been taken listed in section “Repair - Maintenance - Return - Calibration”. By our signature

below, we acknowledge that we accept liability for any damage caused by providing incomplete or incorrect informa-

tion and that we shall indemnify VACUUBRAND from any claims as regards damages from third parties. We are aware

that as expressed in § 823 BGB (Public Law Code of Germany) we are directly liable for injuries or damages suffered

by third parties, particularly VACUUBRAND employees occupied with handling/repairing the product. Shipping of the

device must take place according to regulations.

Name: .................................................................. Signature: ...........................................................................

Job title: ................................................................... Company’s seal:

Date: ........................................................................

Release for repair grant by VACUUBRAND (date / signature): ...................................................................................................................

VACUUBRAND GMBH + CO KG

Alfred-Zippe-Straße 4

97877 Wertheim - Germany

T +49 9342 808-5660 F +49 9342 808-5666

E-Mail: service@vacuubrand.com

www.vacuubrand.com

☐ none