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Documents are only to be used and distributed completely and unchanged. It is strictly the users´ responsibility to check carefully
the validity of this document with respect to his product. 25/11/2013 // 999281
Health and safety clearance form for BVC systems and accessories
1. Device(Model): ...................................................................................................................................
2. Serial no.: ............................................................................................................................................
3. Reason for return / malfunction: ..........................................................................................................
.............................................................................................................................................................
4. Hasthedevicebeenusedinacopperprocessstep(e.g.,semiconductorproduction):
☐ yes ☐ no
5. Substances(gases,liquids,solids,biologicalmaterial,e.g.bacteria,viruses)incontactwiththedevice/
which have been pumped:
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
6. Biohazard safety level of the laboratory: ☐ none ☐ 1 ☐ 2 ☐ 3 ☐ 4
Genetic engineering safety level of the laboratory: ☐ none ☐ 1 ☐ 2 ☐ 3 ☐ 4
7. Risk level of the used biological material: ☐ none ☐ 1 ☐ 2 ☐ 3 ☐ 4
8. Radioactive contamination: ☐ yes ☐ no
9. The following parts have been decontaminated inside and outside prior to sending to the factory and the
effectivity of the decontamination has been ensured:
Bottle .................................................................. ☐ yes ☐ no ☐ not available / not sended
Screw cap ........................................................... ☐ yes ☐ no ☐ not available / not sended
Couplings ........................................................... ☐ yes ☐ no ☐ not available / not sended
Filter ................................................................... ☐ yes ☐ no ☐ not available / not sended
Hoses ................................................................. ☐ yes ☐ no ☐ not available / not sended
HandleVHC ....................................................... ☐ yes ☐ no ☐ not available / not sended
Bottle support ..................................................... ☐ yes ☐ no ☐ not available / not sended
Vacuum pump: Comply with section 10! ......... ☐ yes ☐ no ☐ not available / not sended
Other:............................................................................................................................ ☐ yes ☐ no
If necessary, order instructions for decontamination at VACUUBRAND!
Devices will not be accepted for any handling before we have received this declaration.
Please read and comply with ”Notes on return to the factory” in the instructions for use.
Attention: Only devices free of contamiantion hazardous to health may
send for inspection / repair!
Health and safety clearance form BVC page 1 of 2
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