Appendix A Health And Safety Declaration/Liability Form - GE FineLINE 35 oligo Operating Instructions Manual

Appendix A Health and Safety
GE Healthcare
Biosciences
Health & Safety Declaration Form
RA# __________________
and/or
Service Ticket/Request # _______________
1. Please note that equipment will not be accepted for servicing or return until this form is properly completed
2. Failure to complete the form completely accurately and truthfully can endanger GE Healthcare Bio-Sciences
personnel and may lead to a delay in servicing the equipment.
3. Equipment not sufficiently cleaned prior to return to GE Healthcare Bio-Sciences may be subject to additional
charges.
Equipment type / Product No.
_______________________________________
Serial No
_______________________________________
I hereby confirm that the equipment specified above has been cleaned to
remove any hazardous substances or sanitation solution with exception of
the named liquids (see lower right on this form). I also agree to give GE
Healthcare Bio-Sciences sole control of the system / equipment (specified
above).
Signed................................................................................
Name in
Capital letters.......................................................................
Position in
Institution or company.........................................................
Date
(Year/month/date)
I hereby confirm that I have taken full responsibility and control over the
system / equipment:
Engineer
Signed................................................................................
Name in
capital letters.......................................................................
Date
(Year/month/date)
70-5009-65/AD
Valid from: 2006-05-01
FineLINE 35 oligo column Operating Instructions 28-9649-57 AA
Health and Safety Declaration/Liability Form Appendix A
Declaration/Liability Form
20........../........../..........
Liability Form
20........../........../..........
TO RECEIVE A RETURN AUTHORIZATION NUMBER OR SERVICE NUMBER,
CALL LOCAL TECHNICAL SUPPORT or CUSTOMER SERVICE
Specify if the equipment has been in contact with any of the following:
Radioactivity
(Must be decontaminated prior to service/return)
yes no
Radiation Safety Officer
Signature (required if yes) _________________________________________________
Infectious or hazardous biological substances
yes no (please specify)
____________________________________________________________
(Must be decontaminated prior to service/return)
Other Hazardous Chemicals
yes no
_____________________________________________________________
(Must be completely removed prior to service/return)
Phone number where GE Healthcare Bio-Sciences
can contact you for additional information concerning
the system / equipment
Phone No...........................................................................
Liquid in equipment is:
Water Ethanol None, empty
(Servicing Only)
Changes / Improvements on system or equipment
See PM document
See Service report
None
The owner of the system / equipment confirms by signing in the service report
that he has accepted to take the full responsibility and control.
(please specify)
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