Decontamination Certificate
Document Type:
General Form
Doc Number:
GF-012 Rev. 00
Certification of decontamination and cleaning. After EHS certification return this form with the product.
SEE PAGE 2 FOR INSTRUCTIONS
Name:_________________________
Institution:_______________________
Phone: ______________________
Email:______________________________
Alpaqua Product:________________________
Serial Number:__________________________ (in white on bottom of plate)
This Product is a:
Demo Return
Sealed Return
Opened Return
Repair
This Alpaqua product:
Has never been used with radioactive materials, chemicals, or biological agents
NOTE: Must still be cleaned with detergent solution if unsealed.
Has been used with the following materials:
Chemicals (list all chemicals used)
______________________________________________________________________
Biological Agents (list biological agents used)
______________________________________________________________________
Radioactive Materials (list radioisotopes used)
______________________________________________________________________
The above Alpaqua product has been cleaned with (Use standard decontamination procedures for highest level of contaminate used):
____________________________________________________________________________
Describe process and agents used which is suitable for deactivating/removing/disinfecting the hazardous
materials.
_____________________________________________________________________________________
Name and Title of person doing the decontaminating _______________________________________
Date:____________________________
EHS Sign Off:
I certify that the above Alpaqua Product has been decontaminated and cleaned in accordance with
our institutions decontamination protocols for laboratory equipment.
EHS Officers Name _________________________
Signature ____________________________
Date:______________________
Decontamination Certificate
1. This form should be used to clean all Alpaqua products that have the potential to be
contaminated, (e.g., chemical, biological, radioactive) prior to return to Alpaqua.
2. Once the product has been removed from the lab: remove or deface all safety related, hazard
warning, and inspection stickers from the equipment except for “radioactive” stickers.
3. Identify the equipment by providing Alpaqua product and serial number.
4. Indicate whether the product is a demo return, a sealed unopened return, opened return, or a
repair return.
5. Check the appropriate box indicating whether or not the product has been used with
radioactive materials, chemicals, or biological materials.
6. If the product is unopened and still in its sealed bag it can be returned as is
7: If the product was opened but not used with chemicals, biological and/or radioactive
materials, but was located in a laboratory, the product must still be cleaned with a detergent solution.
Enter the date that the equipment was cleaned.
7. If the product was used with hazardous materials, indicate which type of material by marking
the appropriate box and list the materials used.
8. For usage with chemicals or biological agents, list the name of the chemicals (especially
chemicals which would leave hazardous residue, e.g., blood, mercury, other metals, or other non-volatile
chemicals) or biological agents and clean with the appropriate cleaning solution.
9. Document the cleanup date and the cleaning solution used. Complete the rest of the form and
enclose with return shipment.
10. For usage with radioactive materials, list the radioisotope(s) used and clean with the
appropriate cleaning solution. Document the cleanup date and the cleaning solution used. The product
must also be wipe tested by EHS Radiation officer. Please include the results of this test with this form.
Once cleared by EHS and removed from the lab remove or deface all “radioactive” stickers from the
product. Complete the form following instructions from # 9 above.