Environmental Health, Safety, and Risk Management
Stephen F. Austin State University
Equipment Decontamination Certificate
Bldg Room
Type of
equipment
Manufacturer
Model
No
Serial
No
SFASU
Property
Tag
IMPORTANT
It is the responsibility of the principle investigator (P.I.) to ensure that equipment to be
surplused/disposed of is in a clean and ‘safe’ condition, i.e. free from Microbiological,
Chemical and Radiological contamination.
Please complete the appropriate section below.
1. The equipment described above has not been exposed to micro-organisms, clinical
material, radioisotopes or hazardous chemicals.
Signed: ………………………………………… (P.I.)
Date:……………………………..
2. The equipment described above has been exposed to micro-organisms / clinical material
/ radioisotopes / hazardous chemicals* and appropriate decontamination procedures
have been carried out.
Type of contaminant and methods of decontamination
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………
Signed: ………………………………………… (Cleaner) Date: ……………………………..
Signed: ………………………………………… (P.I.)
Date: ……………………………..
3. Complete decontamination of the equipment described above cannot be achieved.
Nature of residual contamination
…………………………………………………………………………………………...………
Suggested precautions to be observed when handling
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………
Signed: ....................................................…….. (P.I.) Date: ..................................................
(Any queries regarding the content of this certificate to be made to the principle investigator)
____________________________________________________________________
Principle Investigator:……………...................
Contact Information:……………………………
EHSRM:…………………………………..