Hermle Sieva-3, Instruction Manual, Page: 37 / 40

Redemption Form / Decontamination Certificate
Enclose all returned shipping items and modules necessary!
The complete, full declaration about the decontamination is a prerequisite for the assumption and further processing of
the return. If no corresponding explanation is enclosed, we carry out decontamination with costs at your expense.
Surname; Last Name: _____________________________________
Organization / Company: _____________________________________
Street: _____________________________________
ZIP CODE: _____________ place:____________________
Telephone: _____________ fax:____________________
E-Mail: _____________________________________
Pos. Quantity Decontaminated Object Serial No. Description/Comment
1
2
3
4
Are the parts listed above in touch with the following substances?
Health endangering watery solutions, buffers, acids, alkalis:
……….............. ..... 
Yes

No
Potentially infectious agents
: ………………………………………………………... 
Yes

No
Organic reagents and solvent
: ………………………………...……..................... 
Yes

No
Radioactive substances
: ………………………………………..… 
α
..

β
..

γ
..

Yes

No
Health endangering proteins
: …………………………………….……………......... 
Yes

No
DNA: ………………………………………………………………………………….…. 
Yes

No
Have these substances reached the equipment/assembly
? ………………………….. 
Yes

No
If so, which ones:
________________________________________________________________
Description of the measures for the decontamination of the listed parts:
I confirm the proper decontamination:
Company/Dept ._____________ Place and Date: ____________________________________
Signature of the authorized person: ________________________________________
Decontamination Certificate of Goods Returned upon Delivery
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