Lightwave UV/Vis Diode Array Spectrophotometer
39
15
Health & Safety Certificate and Declaration of
Decontamination Status
Before an instrument can be accepted for repair, service or return to stock this form
must be completed and returned to WPA showing that no hazard to health exists to
WPA due to Physical, Chemical, Biological or Radioactive contamination of the
unit. Where the unit has been used in potentially hazardous environments evidence
of decontamination conducted should be given. WPA reserve the right to destroy
the said instrumentation (at the cost of the user) after a period of 3 months has
expired between the instrument being received and the satisfactory completion
of this certificate.
Instrument Model Number ……………………….
Instrument Serial Number
………………………..
Circle A if applicable, otherwise circle and complete all parts of section B
A
This equipment (including any accessories) has not been in contact with
blood or other body fluids, respired gases or pathological samples. It represents no
hazard to health due to Physical, Chemical, Biological or Radioactive contamination
of the unit.
B
1. This equipment been exposed internally or externally to hazardous
materials as indicated below:-
( ) Yes ( ) No
Body fluids, respired gases, pathological samples
( ) Yes ( ) No
Other biohazards
( ) Yes ( ) No
Chemicals or substances hazardous to health
( ) Yes ( ) No
Radioactive hazards
( ) Yes ( ) No
Other hazards
Please attached further details.
2. Has this equipment been cleaned and decontaminated.
( ) Yes ( ) No
How was this contamination removed?……………………………………
................................................................................................................
I declare that I have taken all reasonable steps to ensure the accuracy of the above
information.
Signed ......................................... Name
(print)
...........................................
Company/Establishment…..…………………Position..........................................
Date
...........................................