Appendix C- Decontamination
Certificate
Under
the
provision
of
Postal
Law,
Title
18,
United
States
Code,
Section
1716
and
the
Department
of
Transportation
regulations
contained
in
CFR
49,
Part
173.386
and
173.387,
ʺ
etiologic
agents,
diagnostic
specimens
and
biological
products
…
are
nonmailable…
ʺ
The
undersigned
therefore
certifies
that
the
IRIS
Medical
SL/SLx
is
being
returned
by
______________________________________
_______________________________________
Individual/Institution
City,
State,
Country
and
has
undergone
decontamination
with
a
commercially
available
germicide
cleared
for
use
as
a
“hospital
disinfectant”
and
is
clean
and
free
from
biohazards,
including,
but
not
limited
to,
human
or
animal
blood,
tissue
or
tissue
fluids
or
components
thereof.
The
undersigned
also
agrees
to
reimburse
IRIDEX
for
any
costs
incurred
in
cleaning
the
enclosed
equipment,
in
the
event
that
said
item(s)
is/are
received
by
IRIDEX
in
a
contaminated
condition.
____________________________________
____________________________________
____________________________________
____________________________________
Model ________________________________
Model _________________________________
______________________________________
_______________________________________
Serial
# ________________________________
Serial
# ________________________________
IRIDEX
RMA
# _________________________
IRIDEX
RMA#__________________________
Typed/Printed
Name ___________________
Typed/Printed
Name ____________________
______________________________________
_______________________________________
Signature ______________________________
Signature ______________________________
OcuLight SL/SLx Operator Manual
PN 13099D-EN
43
