Service Work Order Request

This has, or may have caused or contributed to, a death or serious injury or could have caused injury*

NoYes

Ship repaired item to*

Sender Customer

Decontamination Declaration

In order to ensure the highest level of safety for our Repair Technicians we require the equipment returned be clean, and someone from the organization taking responsibility for declaring the unit clean, or declaring the item was contaminated and describing the steps taken to clean it. Before returning items to our In-House Repair facility, we ask that you thoroughly clean, decontaminate, and if necessary disinfect the item. Alternatively, please indicate and confirm that the Olympus item has not come in contact with any hazardous substances. Beyond being compliant, our Technicians thank you.

This form must be completed by a knowledgeable, competent person aware of all substances in contact with the item prior to completing this declaration.

Please check one:*

I hereby affirm the item named above has NOT come in contact with hazardous or infectious samples or reagents.

I hereby affirm the item named above has been properly cleaned / decontaminated.

Safety level of the Lab the Item was returned.

N/ABLS-2BSL-3BLS-4

The Item / Equipment listed above has come in contact with:

Radioactive Substances

List of substances

Decontaminated with: *

List of de-contaminant(s)

Isotope(s): *

List of isotope(s)

Additional Notes (if applicable):

Enter text

Chemical Substances

List of substances

Decontaminated with: *

List of de-contaminant(s)

Specifications: *

List of specifications

GHS / SDS Statement: *

Add statement

Additional Notes (if applicable):

Enter text

Infectious Biological Material

List of substances

Decontaminated with: *

List of de-contaminant(s)

Specifications: *

List of specifications

GHS / SDS Statement: *

Add statement

Additional Notes (if applicable):

Enter text

Other Hazardous Material

List of substances

Decontaminated with: *

List of de-contaminant(s)

Specifications: *

List of specifications

GHS / SDS Statement: *

Add statement

Additional Notes (if applicable):

Enter text

I understand that by checking this box and entering my full name I am signing this document electronically. *

Responsible Party Printed Name *

Service Work Order Request

Service Work Order Request

Sender

Customer

Product(s) Enclosed:

Detailed Description of Problem

Product Environment / Background

Service Requested

Decontamination Declaration

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