Rev. 4-16a
17
11. SAFETY CERTIFICATION FORM
Items being returned:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please check only one item below:
___ The equipment was never used or exposed to any radiological, biological or chemical
agents and is safe to handle, use or dispose of.
___ The equipment was used but not in conjunction with or exposed to any radiological,
geological or chemical agents and is safe to handle, use, or dispose of.
___The equipment was used in conjunction with or exposed to radiological, biological, or
chemical agents and has been decontaminated, rendering it safer for handling, use, or
disposal.
Authorization
By accepting authorization to return the equipment listed above, the undersigned assumes all
responsibility and liability for radiological, biological and chemical decontamination. Delivery of
the equipment can be refused if necessary documentation is not provided or where it is
determined that the equipment has not been properly decontaminated. If it is determined that
the equipment was not properly decontaminated, the Authorized Repair Facility reserves the
right to bill the customer for any and all costs associated with the decontamination and/or
appropriate disposal of the equipment. In the event the equipment has been exposed to
radiological contamination, the signature of the Radioactive Safety Officer is required.
Print name: ___________________________________ RA # ___________________
Signature: ____________________________________ Date: __________________
