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9
Returns Authority & Decontamination Note
Note – You must complete the following form before returning the equipment, failure to
do so may result in a refusal to accept the shipment and may cause delays in
processing the service or repair.
Customer
Address
Contact Name
Contact Details
Product Number & Serial Number
7000SMZ-
Product Name / Description
Description of problem / reason for return. (Continue on separate sheet if necessary)
Please note: Blade must be removed from the blade holder
The following Declaration of Decontamination status applies to all items returned to Campden
Instruments. If the answers to Sections A2 and all B questions are NO then ignore Sections D to F.
Otherwise all Sections must be completed. You must complete and sign the Declaration.
A
1. Has the package been opened? YES/NO 2. Has the product been used? YES/NO
B
Has the product been exposed internally or externally to any of the following?
1.
Biological Hazards (pathogenic viruses, bacteria, fungi etc ) YES/NO
2.
Radioactive Sources YES/NO - **IF YES DO NOT RETURN**
3. Chemical Hazard (mercury, salts, acids, bases etc) YES/NO
4. Rabies, BSE, CJD, nCJD etc YES/NO
5. Any Other Hazard – PLEASE SPECIFY – YES/NO
C
Does your laboratory contain animals that need to be shielded against pathogens? YES/NO
D
Provide details of any hazard indicated above. Include detail of names and quantities of
agents, Material Safety Data Sheets and First Aid Information.
E
Describe your methods of decontamination, including agents used for this purpose.
F
Are there likely to be any areas of residual contamination? Please be specific.
DECLARATION
– I declare that the information given above is true and complete to the best of my
knowledge and belief, and that I have taken all reasonable steps to ensure its accuracy. If there is any
subsequent outbreak of an infectious agent in my laboratory I will inform Campden Instruments
immediately.
Authorised Signature………………………………
Date………………………….
Name (Print)……………………………………. …. Position………………………
Tel No………………………………………………
Fax No………………………..
Number
Date
Return Address
4, Park Road, Sileby, Loughborough. LE12 7TJ. U.K.
Returns from outside the EU must be stated as “Returns of Nominal Value”.
Failure to do this will incur customs charges.
Summary of Contents for 7000smz
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