VACUUBRAND 8-channel tip adapter with ejector : Instruction Manual : Page 27

page 27 of 29

Health and safety clearance form for BVC systems and accessories

1. Device (Model): ...................................................................................................................................

2. Serial no.: ............................................................................................................................................

3. Reason for return / malfunction: ..........................................................................................................

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

4. Has the device been used in a copper process step (e.g., semiconductor production):

☐ yes ☐ no

5. Substances (gases, liquids, solids, biological material, e. g. bacteria, viruses) in contact with the device /

which have been pumped:

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

6. Biohazard safety level of the laboratory: ☐ none ☐ 1 ☐ 2 ☐ 3 ☐ 4

Genetic engineering safety level of the laboratory:

☐ none ☐ 1 ☐ 2 ☐ 3 ☐ 4

7. Risk level of the used biological material: ☐ none ☐ 1 ☐ 2 ☐ 3 ☐ 4

8. Radioactive contamination:

☐ yes ☐ no

9. The following parts have been decontaminated inside and outside prior to sending to the factory and the

effectivity of the decontamination has been ensured:

Bottle .................................................................. ☐ yes ☐ no ☐ not available / not sended

Screw cap ........................................................... ☐ yes ☐ no ☐ not available / not sended

Couplings ........................................................... ☐ yes ☐ no ☐ not available / not sended

Filter ................................................................... ☐ yes ☐ no ☐ not available / not sended

Hoses ................................................................. ☐ yes ☐ no ☐ not available / not sended

Handle VHC ....................................................... ☐ yes ☐ no ☐ not available / not sended

Bottle support ..................................................... ☐ yes ☐ no ☐ not available / not sended

Vacuum pump: Comply with section 10! ......... ☐ yes ☐ no ☐ not available / not sended

Other: ............................................................................................................................ ☐ yes ☐ no

If necessary, order instructions for decontamination at VACUUBRAND!

Devices will not be accepted for any handling before we have received this declaration.

Please read and comply with ”Notes on return to the factory” in the instructions for use.

Attention: Only devices free of contamiantion hazardous to health may

send for inspection / repair!

Health and safety clearance form BVC page 1 of 2