AI0-IF-025-00
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Certificate of Decontamination (Sample)
End of document.
If you are returning any used medical device to Sakura Finetek Group, please provide the following information
to help prevent contamination of other devices, etc., or living environment at our facility and the workers who
will be working on/handling your device. Fill out this Certificate of Decontamination and return it with the device.
If the device is not accompanied by this certificate, we will not unpack or repair the instrument. If the returned
medical device is deemed hazardous by Sakura Finetek Group, we will return the device to you immediately.
The cost of shipment will be borne by you.
Date:
Institution name:
Equipment information
[Instrument name]
[Model]
[Serial number]
Please answer the following questions regarding the usage status. (Circle where applicable. Use the Remarks field, if
necessary.)
Question
Answer
Remarks
1. Has this device been used at a hospital where legally designated
communicable diseases are treated?
Yes
No
2. Has this device been used in a ward where patients of legally
designated communicable diseases are staying?
Yes
No
3. Has this device been used in a room where pathological work on
infectious diseases is conducted?
Yes
No
4. Has this device been used in a room where testing of infectious
diseases is conducted?
Yes
No
5. Has this device been used in a room where articles used in
connection with infectious diseases are disposed of?
Yes
No
6. Has this device been used in a room where research on special
viruses is conducted?
Yes
No
7. Has this device been used in a room where articles used in
connection with special viruses are disposed of?
Yes
No
Please answer questions regarding disinfection.
Whenever possible, please return the device after cleaning/disinfecting it using general disinfectant, primarily in areas
that likely came in contact with tissues, operators, etc.
Examples of general disinfectants: Disinfecting alcohol, 70% isopropanol, biguanide alcohol, benzalkonium chloride,
Chlorhexidine
1. Date of disinfection
2. Method of disinfection
Remarks
