Gow-Mac 75-800, Руководство по эксплуатации

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Health and Safety Declaration for the Return of GOW-MAC Instrument Co. Equipment
In order to protect our employees from exposure to various hazards, the following
statements and/or questions MUST be answered by you. Fill out this document
in its entirety and either fax or e-mail it to GOW-MAC Instrument Co., Attn:
Repair Dept, BEFORE returning the product.
The instrument/part being returned will not be accepted into GOW-MAC’s facility
until we receive this completed document, along with a PO or Credit Card . Once
approved for return by our Chemical Safety Officer, a Return Materials
Authorization (RMA) number and shipping instructions will be issued. All
applicable regulations should be followed when returning instrumentation,
and/or parts.
Customer to Record the Following:
Model # / Part # ________________________________
Serial #:____________________
Service Technician spoken to:
Today’s Date:
IF THIS FORM IS NOT APPROVED BY OUR CHEMICAL SAFETY OFFICER, THE INSTRUMENT/PART WILL NOT BE PERMITTED INTO
OUR FACILITY FOR SERVICING!
A] Brief explanation of issue:_______________________________________________________________________________________
B] Briefly list the application(s) for which the instrument/part was used, as well as any and all chemicals, gases, and/or materials
analyzed and their concentrations. (
Must be filled in ): ________________________________________________________________
C] Is there the possibility of internal or external contamination on or in this instrument/part?
Yes – see below No – proceed to D.
Please check the appropriate box.
Chemicals or Substances That Are Hazardous to Health
Blood, Body Fluids, (e.g. Urine, Secretions), Pathological Specimens
Regulated Medical Wastes
Infectious Substances or other Bio-Agents (e.g. Protein, Enzymes, Antibodies)
Radioactive Isotopes used in the area. Detail type (ECD, Isotopic Labels, etc) and Activity in Micro Curies
Biodegradable Material That Could Become Hazardous
Other Hazards
If any of the above boxes are checked the following statements and/or questions must be answered.
1. Specifically describe where (on or in) the instrument/part there could be any residual contamination (for example: blood spill on the
surface).
2. Provide details of these hazards. Include names, Material Safety Data Sheets (MSDS), and concentration of contaminants, where
possible.
3. Describe the method of decontamination used. Attach Procedure.
D] I declare that the above information is true and complete to the best of my knowledge. I acknowledge that any inconsistencies between
the condition of the instrument and the statements made on this form will delay the repair process.
Authorized signature
Date:
Name (Printed) Phone number:
Company name:
Fax number:
Shipping address: ___________________________
City: State/Country: Zip :
E-mail address: _
BEFORE item can be shipped, fax completed form to: (610) 954-0599 or e-mail it to: repairs@gow-mac.com
For GOW-MAC Use Only: Signed: Date _/ /
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Passed Safety Inspection. OK to proceed to Repair Dept. Chemical Safety Officer Comments: ( ) None
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Failed safetyInspection. DO NOT proceed to Repair Dept. RMA No: ( ) On Back >>>>
REP-005
Health-Safety Declaration Doc
– ONLINE
Rev.7 1/28/2022, kj