Datex-Ohmeda Anesthesia Delivery Unit S/5, Technical Reference Manual

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Datex-Ohmeda ADU
7-10
Document No. 8502852
Health and safety declaration form
1. Please note that equipment returned for service, will not be accepted until this form is properly
completed.
2. Failure to complete the form or to comply with health and safety cleaning procedures, may
endanger Datex-Ohmeda service personnel and may lead to delay in servicing the equipment.
Equipment type/Product No: State if the equipment has been in contact
with any toxic or hazardous substances that
require the service personnel to wear:
Serial No:
I hereby confirm that the above equipment
has been properly cleaned and
decontaminated. I also agree to give Datex-
Ohmeda the sole control of the instrument /
system.
Cleaning certified:
(signature)
Gloves
Inhalation filter
Protective clothing
Other:....................................................
....................................................................
....................................................................
..........................................................……….
Name:
(Block letters)
None of the above
Position in institution or company: State phone number where Datex-Ohmeda
may obtain more information concerning the
instrument / system.
Date (YY/MM/DD)
/ /
Phone No: