Michell Instruments SF52 User Manual page 26

APPENDIX D
Appendix D Return Document & Decontamination Declaration
IMPORTANT NOTE: Please complete this form prior to this instrument, or any components, leaving your
site and being returned to us, or, where applicable, prior to any work being carried out by a Michell
engineer at your site.
Instrument
Warranty Repair?
Company Name
Address
Telephone #
Reason for Return /Description of Fault:
Has this equipment been exposed (internally or externally) to any of the following?
Please circle (YES/NO) as applicable and provide details below
Biohazards
Biological agents
Hazardous chemicals
Radioactive substances
Other hazards
Please provide details of any hazardous materials used with this equipment as indicated above (use continuation sheet
if necessary)
Your method of cleaning/decontamination
Has the equipment been cleaned and decontaminated?
Michell Instruments will not accept instruments that have been exposed to toxins, radio-activity or bio-hazardous
Work will not be carried out on any unit that does not have a completed decontamination declaration.
Decontamination Declaration
I declare that the information above is true and complete to the best of my knowledge, and it is safe for Michell
personnel to service or repair the returned instrument.
Name (Print)
Signature
20
YES NO
SF52 User's Manual
Serial Number
Original PO #
Contact Name
E-mail address
YES
YES
YES
YES
YES
YES
Position
Date
F0121, Issue 2, December 2011
97224 Issue 5, June 2017
NO
NO
NO
NO
NO
NOT NECESSARY