A
Decontamination form - sample copy
This "Certi
fi
cate of Decontamination" is intended to protect the occupational health and
safety of our employees pursuant to the German Protection against Infection Act and the
trade association accident prevention regulations.
Please understand that we cannot start work until this Certi
fi
cate has been submitted.
Before sending the device back to us for inspection/repair, the device and accessories
must be cleaned pursuant to current laws and regulations and, if necessary, must also
be disinfected with a surface disinfection agent listed by the VAH (Alliance for Applied
Hygiene).
Device type:
Serial number:
Accessories:
Device /accessories ...
are not contaminated:
were cleaned before shipping?
are free from contaminants?
have been decontaminated and/or disinfected and no longer pose
a health hazard?
Has the device / accessories been in contact with contaminants?
Corrosive
Biologically hazardous (e.g. micro-organisms)
Toxic
Radioactive
None
Certi
fi
cate of Decontamination
! ! ! CAUTION ! ! !
Attach this form in a clearly visible location
on the outside of the packing!
