GE Services On Site Service Health &
Safety Declaration Form
Service Ticket #:
To ensure the mutual protection and safety of GE Healthcare service personnel and our customers, all equipment and work
areas must be clean and free of any hazardous contaminants before a Service Engineer starts a repair. To avoid delays in the
servicing of your equipment, please complete this checklist and present it to the Service Engineer upon arrival. Equipment and/
or work areas not sufficiently cleaned, accessible and safe for an engineer may lead to delays in servicing the equipment and
could be subject to additional charges.
Yes No
Please review the actions below and answer “Yes” or “No”. Provide explanation for any “No” answers
in box below.
Instrument has been cleaned of hazardous substances.
Please rinse tubing or piping, wipe down scanner surfaces, or otherwise ensure removal of any dangerous
residue. Ensure the area around the instrument is clean. If radioactivity has been used, please perform a
wipe test or other suitable survey.
Adequate space and clearance is provided to allow safe access for instrument service, repair
or installation.
In some cases this may require customer to move equipment from normal operating location prior
to GE arrival.
Consumables, such as columns or gels, have been removed or isolated from the instrument and from
any area that may impede access to the instrument.
All buffer / waste vessels are labeled. Excess containers have been removed from the area to
provide access.
Provide
explanation
for any “No”
answers here:
Equipment type / Product No: Serial No:
I hereby confirm that the equipment specified above has been cleaned to remove any hazardous substances and that the area
has been made safe and accessible.
Name in Capital letters:
Company or institution:
Position or job title: Date (Year/month/date): 200000/00000/00000
GE, imagination at work and GE monogram are trademarks of General Electric Company.
GE Healthcare Bio-Sciences Corp, 800 Centennial Avenue, P.O. Box 1327, Piscataway,
NJ 08855-1327, USA.
© 2010-12 General Electric Company—All rights reserved. First published April 2010.
28-9800-26 AB 05/2012
Signed:
DOC1149542
To Next Page
Loading...
Need help?
General
