Health And Safety Clearance Form - vacuubrand BVC Basic Instructions For Repair

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:
* 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:
7. Prior to return to the factory the device has been decontaminated:
Description of the decontamination method and the test / verification procedure:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
8. All parts of the device are free of hazardous, harmful substances:
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):
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
Health and safety clearance form
: ...................................................................................................................
T +49 9342 808-5660 F +49 9342 808-5666
E-Mail: service@vacuubrand.com
www.vacuubrand.com
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