DECLARATION OF DECONTAMINATION
AND REPAIR FORM
Please complete all applicable sections, email a copy to [email protected] and
include the original with your shipment. One form is sufficient for multiple items in one
shipment being returned to Chemglass Life Sciences.
NOTE: Failure to complete this form may result in delays or rejection of ware.
PART 1: Information: Please provide physical address.
RMA # __________________
Company___________________________________________________________
Address ____________________________________________________________
Address ____________________________________________________________
City _____________________________State ______________ Zip_____________
Contact ________________________________Phone_____________ Email_________________________
Alternate _______________________________Phone_____________ Email_________________________
Product_________________________ Serial #________________ Issue:____________________________
Product_________________________ Serial #________________ Issue:____________________________
Product_________________________ Serial #________________ Issue:____________________________
Product_________________________ Serial #________________ Issue:____________________________
Additional Issues and/or Comments: __________________________________________________________
_______________________________________________________________________________________
PART 2: Declaration of Decontamination: In order to ensure the adequate protection of our
personnel, Chemglass Life Sciences requires our customers to declare the types of substances that have
been in contact with the product(s) you are returning. As part of the returns authorization process, you are
responsible for the decontamination of your product prior to shipping.
Has this equipment/product been used with dangerous, toxic, poisonous, corrosive, radioactive or any other
hazardous materials?
NO
YES
If YES, please specify type(s), attach additional pages if needed.
Type(s):_________________________________________________
Can this equipment be handled and disassembled safely without risk?
NO
YES

If you need assistance with decontamination instructions please consult the product manufacturer or
Chemglass Life Sciences Technical Service at 1-800-843-1794; Press 1 and ext. 2898.
PART 3: Authorizing Signature
I, _________________________________, certify that I am the equipment owner/user, or I am authorized to
act on their behalf, and the referenced product has been decontaminated and tested for radiation level
hazard(s) and/or potential hazard(s) from bio-hazardous materials and/or chemicals.
Signature ______________________________________
RFDOD-01
August 2016
Date: ___________________