Equipment Decontamination Certificate

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					Equipment Decontamination Certificate BUILDING ROOM No

TYPE OF EQUIPMENT

MANUFACTURER

MODEL No.

SERIAL No

IMPORTANT It is the responsibility of the user to ensure that equipment to be left/relocated/disposed of is, so far as is reasonably practicable, in a clean and ‘safe’ condition, i.e. free from Microbiological, Chemical and Radiological contamination. Please complete the appropriate section below. 1. The equipment described above has not been exposed to micro-organisms, clinical material, radioisotopes or hazardous chemicals. Signed: ………………………………………… (User) Date:……………………………..

2. The equipment described above has been exposed to micro-organisms / clinical material / radioisotopes / hazardous chemicals* and appropriate decontamination procedures have been carried out. Signed: ………………………………………… (User) Date: ……………………………..

3. Complete decontamination of the equipment described above cannot be achieved. Nature of residual contamination …………………………………………………………………………………………...……… Suggested precautions to be observed when handling …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… Signed: ....................................................…….. (User) Date: .................................................. (Any queries regarding the content of this certificate to be made to this person) ____________________________________________________________________ Laboratory Manager Authorisation Signature: .............................................................. Date: ……………………………………. *Please delete as appropriate Name: .......................................