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11.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.
1.
Clean the optical head according to the instructions in Section 11.A.
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 contaminated by body fluids or by toxic, carcinogenic, radioac-
tive, 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
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
Biological
Radioactive**
17
TM276 · Revised 5/21
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