Certificate Of Decontamination - Promega GloMax Operating Manual

7.D. Certificate of Decontamination
Disinfection and decontamination are required before shipping the instrument and instrument accessories
for repair. Instruments returned for service must be accompanied by a signed and dated Certificate of
Decontamination, which must be attached to the outside packaging of the instrument. Print this page, fill out,
sign and return along with the instrument for repair.
1 Clean the interior of the instrument according to the instructions in Section 5.B.
2. Clean the injectors according to the instructions in Section 5.E.
3. Clean the Waste Collection Tray according to the instructions in Section 5.F.
Failure to confirm disinfection and decontamination will result in decontamination charges before the instrument
will be serviced.
Select either (A) or (B):
A. I confirm that the returned items have not been used with body fluids or contaminated by toxic,
carcinogenic, radioactive or other hazardous materials.
B. I confirm that the returned items have been decontaminated and can be handled without exposing personnel
to health hazards.
Circle the type of material used in the instrument:
Chemical Biological
Briefly describe the decontamination procedure performed: ____________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date: ____________________________________
Place: ____________________________________
Signature: _________________________________
Name (block capital letters): ________________________________________________________
** The signature of a Radiation Safety Officer is also required if the instrument was used with radioactive materials.
This instrument is certified by the undersigned to be free of radioactive contamination.
Date: ____________________________________
Place: ____________________________________
Signature: _________________________________
Name (block capital letters): ________________________________________________________
Promega Corporation · 2800 Woods Hollow Road · Madison, WI 53711-5399 USA · Toll Free in USA 800-356-9526 · 608-274-4330 · Fax 608-277-2516
www.promega.com
Radioactive**
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TM397 · Revised 8/18