Page 16 of 20 M6627 Issue 7.0
APPENDIX ‘A’. DECONTAMINATION CERTIFICATE.
Electrothermal.
Electrothermal House. Unit12A, Purdeys Way. Purdeys Industrial Estate. Rochford. Essex. SS4
1ND. Great Britain
Phone:+44(0)1702 303350 Fax:+44(0)1702 468731. E-mail: [email protected]
DECONTAMINATION CLEARANCE CERTIFICATE
For the Inspection, Repair or Return of Medical, Laboratory or Industrial Equipment.
Prior to a Service Engineer working on equipment that has been in an environment where substances hazardous to health
may have been used, you are requested to provide the following information:
CUSTOMER DETAILS
Company:-
Address:-
Department:-
Contact Name:-
Tel No:-
Fax No:-
Post Code:-
Product Description
Model No:-
Serial No:-
Has the equipment been exposed to any of the following, Please answer all questions by deleting YES/NO as applicable and by providing
details in section 2 below.
A. Blood, body fluids, Pathological
specimens
YES/NO
Provide details if YES
B. Biodegradable material that could
become a hazard
YES/NO
Provide details if YES
C. Other biohazard
YES/NO
Provide details if YES
D. Chemical or substances hazardous to
health
YES/NO
Provide details if YES
E. Radioactive substances State name(s)
and quantities of isotopes and checks
made for residual activity
YES/NO
Provide details if YES
F. Other hazards
YES/NO
Provide details if YES
2. Please provide details of any hazard present as indicated above. Include details of names and quantities of
agents as appropriate:-
3. Your method of decontamination (please describe):-
4. Are there likely to be any areas of residual contamination (please specify)
I declare that the above information is true and complete to the best of my knowledge and
belief.
Authorised signature:-
Name (please print):-
Title/Position:-
For and behalf of:-
Date:-
