8.5
Health and Safety Declaration Form
On site service
Service Ticket #:
To make the mutual protection and safety of Cytiva service personnel and our customers, all equipment and work areas must be
clean and free of any hazardous contaminants before a Service Engineer starts a repair. To avoid delays in the servicing of your
equipment, complete this checklist and present it to the Service Engineer upon arrival. Equipment and/or work areas
not sufficiently cleaned, accessible and safe for an engineer may lead to delays in servicing the equipment and could be subject to
additional charges.
Yes
No
Review the actions below and answer “Yes” or “No”.
Provide explanation for any “No” answers in box below.
Instrument has been cleaned of hazardous substances
.
Rinse tubing or piping, wipe down scanner surfaces, or otherwise make sure removal of any dangerous residue.
Make sure the area around the instrument is clean. If radioactivity has been used, perform a wipe test or other
suitable survey.
Adequate space and clearance is provided to allow safe access
for instrument service, repair or
installation. In some cases this may require customer to move equipment from normal operating location
prior to Cytiva arrival.
Consumables, such as columns or gels, have been removed or isolated from the instrument and from
any area that may impede access to the instrument .
All buffer / waste vessels are labeled.
Excess containers have been removed from the area to provide access.
Provide
explanation
for any “No”
answers here:
Equipment type / Product No:
Serial No:
I hereby confirm that the equipment specified above has been cleaned to remove any hazardous substances and that the area
has been made safe and accessible.
Name:
Company or institution:
Position or
job title:
Date (YYYY/MM/DD):
Signed:
Cytiva and the Drop logo are trademarks of Global Life Sciences IP Holdco LLC or an affiliate.
© 2020 Cytiva.
All goods and services are sold subject to the terms and conditions of sale of the supplying company operating
within the Cytiva business. A copy of those terms and conditions is available on request. Contact your local Cytiva
representative for the most current information.
For local office contact information, visit cytiva.com/contact.
28980026 AD 04/2020
On Site Service Health &
Safety Declaration Form
8 Reference information
8.5 Health and Safety Declaration Form
Monitor UVis-920 Operating Instructions 29055049 AF
91
