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Health and safety clearance form

1. Device (Model):

Health and safety clearance form

..................................................................................................................................................

Health and safety clearance form

2. Serial no.:

Health and safety clearance form

...........................................................................................................................................................

3. Reason for return / malfunction: .........................................................................................................................

............................................................................................................................................................................

4. Has the device been used in a copper process step (e.g., semiconductor production):

yes no

5. Substances (gases, liquids, solids, biological material, e. g. bacteria, viruses) in contact with the device /

which have been pumped:

............................................................................................................................................................................

6. Risk level of the used biological material:

none

3**

4**

* Contact the VACUUBRAND service absolutely before dispatching the device.
** Devices which have been in contact with biological substances of risk level 3 or 4 cannot be checked, main-

tained or repaired. Also decontaminated devices must not returned to VACUUBRAND due to a residual risk.

7. Radioactive contamination:

yes no

8. Prior to return to the factory the device has been decontaminated:

yes no

............................................................................................................................................................................

9. All parts of the device are free of hazardous, harmful substances:

yes no

10.Protective measures required for service staff:

............................................................................................................................................................................

11.If the paint is damaged, we wish a repaint or a replacement of parts for reason of appearance

(repaint and replacement at customer’s expense):

yes no

12.Legally binding declaration

We assure for the returned device that all substances, which have been in contact with the device are listed in
section 5 and that the information is complete and that we have not withheld any information. We declare that all
measures - where applicable - have been taken listed in section “Repair - Maintenance - Return - Calibration”.
By our signature below, we acknowledge that we accept liability for any damage caused by providing incom-
plete or incorrect information and that we shall indemnify VACUUBRAND from any claims as regards damages
from third parties. We are aware that as expressed in § 823 BGB (Public Law Code of Germany) we are directly
liable for injuries or damages suffered by third parties, particularly VACUUBRAND employees occupied with
handling/repairing the product. Shipping of the device must take place according to regulations.

Name: .................................................................. Signature: ...........................................................................

Job title: ................................................................... Company’s seal:

Date: ........................................................................

Release for repair grant by VACUUBRAND (date / signature)

...................................................................................................................

..............................................................

Protective measures:

VACUUBRAND GMBH + CO KG
Alfred-Zippe-Straße 4
97877 Wertheim - Germany

T +49 9342 808-5660 F +49 9342 808-5666
E-Mail: [email protected]
www.vacuubrand.com