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APPENDIX D: SERVICE SAFETY ASSURANCE FORM
Use this form to request authorization to return and/or process the following:
________________________ ________________________ _____________________
Model Name Model Number Serial Number
Before Cole-Parmer issues authorization for return and/or processing of the product identified above, the following
information must be provided by a qualified and responsible representative of your organization:
Was the product ever exposed to (or did it ever contain) toxic, hazardous, infectious, or otherwise harmful materials?
YES_______ NO_______
If yes, please completely identify all such materials and answer the following questions:
( ) Poisonous Material
( ) Radioactive Material
( ) Corrosive Material
( ) Biological / Infectious Substance
( ) Mercury
( ) Flammable / Combustible Material
( ) Carcinogen
( ) Oxidizer
( ) Other________________________________
Material Types: Please supply Material Safety Data Sheets if available. (Use additional sheets if necessary):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Has the product been properly cleansed, disinfected, or sterilized so that it is now safe for human handling?
YES___ NO___
Which sterilization / disinfectant process was used in cleaning this product?
( ) Hydrogen Peroxide
( ) Peracetic Acid
( ) Glutaraldehyde
( ) Chlorine Dioxide
( ) Chlorous Acid
( ) Iodophor
( ) Ethyl Alcohol
( ) Isopropyl Alcohol
( ) Phenolic Compounds
( ) Chlorine Compounds
( ) Formaldehyde
( ) Quaternary Ammonium
( ) Other________________________________________
Are there any additional safety precautions that should be taken? YES_____ (Describe in detail below) NO_____
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Cole-Parmer relies on the accuracy and completeness of this information to protect our employees from injury by exposure
to toxic, hazardous, infectious, or otherwise harmful materials. It is imperative that you provide Cole-Parmer with all
necessary information.
Name__________________________________ Signature_____________________________________
Title___________________________________ Date_________________________________________
Company_______________________________
Telephone / E-Mail_____________________________
Return or Fax to:
COLE-PARMER
ATT: Service Dept.
625 East Bunker
Court
Vernon Hills, IL
60061-9872
(800) 323-4340 FAX: (877) 693-9273
Mail or Fax to:
ATT: Cole-Parmer Service Dept.
935 Mearns Road,
Warminster, PA 18974
FAX: (877) 693-9273
