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7 Reference information
7.2 Health and Safety Declaration Form
7.2
Health and Safety Declaration Form
On site service
Serv
vice Ticket #
#:
To ma
ke the mutual
protection an
clean a
and free of any
y hazardous c
equipm
ment, please c
complete this c
not su
fficiently clean
ned, accessible
additio
onal charges.
Please review
P
Yes
No
P
Provide expla
I
Instrument ha
P
Please rinse tu
residue. Ensur
r
wipe test or ot
w
A
Adequate spa
installation. In
i
prior to GE arr
p
C
Consumables
any area that
a
A
All buffer / wa
E
Excess contai
Provi
de
expla
anation
for an
ny "No"
answ
wers here:
Equip
pment type /
Product No:
I here
eby confirm th
hat the equipm
area
has been mad
de safe and ac
Nam
e:
Posit
tion or
job ti
itle:
Signe
ed:
52
nd safety of GE
E service perso
onnel and our c
contaminants b
before a Servic
ce Engineer st
checklist and p
present it to the
e Service Engi
e and safe for
an engineer m
may lead to de
w the actions b
below and ans
swer "Yes" or
nation for any
y "No" answe
ers in box belo
as been clean
ed of hazardo
ous substance
ubing or piping
g, wipe down s
scanner surfac
e the area aro
ound the instru
ument is clean
ther suitable s
urvey.
ce and cleara
nce is provide
ed to allow saf
some cases t
his may requir
re customer to
rival.
s, such as colu
umns or gels, h
have been rem
t may impede
access to the
e instrument .
aste vessels a
re labeled.
ners have bee
en removed fr
from the area
ment specified
above has bee
en cleaned to
ccessible.
On Site
e Servic
Safety
y Declar
customers, all
equipment an
arts a repair. T
To avoid delays
neer upon arr
ival. Equipmen
lays in servicin
ng the equipm
"No".
ow.
es.
ces, or otherw
wise ensure rem
. If radioactivit
ty has been us
e access for in
nstrument serv
o move equipm
ment from nor
moved or isola
ated from the
to provide ac
ccess.
Seria
l No:
remove any h
hazardous sub
Comp
pany or institu
ution:
Date
(YYYY/MM/DD
D):
GE and GE
monogram are trade
emarks of General E
GE Healthc
are Bio-Sciences Co
rp, 800 Centennial A
NJ 08855-1
1327
© 2010-14
General Electric Com
mpany—All rights res
Frac-920 and Frac-950 Operating Instructions 28-9622-09 AC
ce Hea
lth &
ration F
Form
nd work areas
must be
s in the servici
ng of your
nt and/or work
k areas
ent and could
be subject to
moval of any d
angerous
sed, please pe
rform a
vice, repair or
rmal operating
g location
e instrument a
and from
bstances and t
hat the
Electric Company.
Avenue, P.O. Box 132
7, Piscataway,
served. First publishe
ed April 2010.
D
DOC1149542/28-980
00-26 AC 05/2014
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