Decontamination Report

______________________________________________________________________

Document number: 04-0051-11

Edition: AA

1. Equipment that is returned, for service or any other reason when personnel connected to GE Healthcare must handle

the equipment (at any location), should be cleaned.

2. This form must be used to log the decontamination of the equipment.

3. A completed copy of this form should be faxed or sent by first class post to the person who will come in contact with

the equipment, to ensure that he/she has the information before handling the equipment.

4. Failure to complete the form or comply with the procedure will lead to costs for decontamination and delays in hand-

ling the equipment.

5. Company:................................................................................................ Address:.......................................................................................................

Phone:....................................................................................................... Fax number:...............................................................................................

6. Please complete the following sections

6.1 Equipment type.................................................................................... 6.2 Serial number ....................................................................................

6.3 Details of substances used on the inside/outside of the equipment

6.3.1 Substance name(s):

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

6.3.2 Precautions to be taken in handling these substances:

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

6.3.3 Action to be taken in the event of human contact:

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

6.3.4 Cleaning fluid to be used if residue of chemicals is found during handling:

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

6.4 Any further relevant information:

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

7. If any substances used in the system are hazardous or toxic, these must be highlighted under 6.3.1.

I hereby confirm that the equipment has been thoroughly cleaned, whether or not the equipment has been in contact

with toxic and hazardous substances, and that the equipment has been filled with a suitable solution. I have also at-

tached a description of the cleaning method.

Storage solution in equipment:...........................................................................................................................................................................................

Signed:.............................................................................................. Name: .......................................................................................................................

Position:............................................................................................ Date:..........................................................................................................................