Page 79 of 80
M8024 Issue 3.4
For use with master product
software V3.5.1.8 and above.
APPENDIX ‘A’. DECONTAMINATION CERTIFICATE.
Bibby Scientific Limited
.
Beacon Road, Stone, Staffordshire ST15 0SA. Great Britain
Tel: +44(0)1785 812121. Fax: +44(0)1785 810405
DECONTAMINATION CLEARANCE CERTIFICATE
For the Inspection, Repair or Return of Medical, Laboratory or Industrial Equipment.
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:-
