ENVIRONMENTAL HEALTH AND SAFETY FORM
PLEASE FILL OUT ALL INFORMATION AND RETURN FORM WITH YOUR SHIPMENT. Please fold and insert this form into the shipping label holder in
a HIGHLY VISIBLE LOCATION ON THE EXTERIOR OF EACH CONTAINER. PRODUCTS WILL NOT BE ACCEPTED WITHOUT FORM.*
Please RETURN to:
Agilent Technologies Deutschland GmbH
c/o LGI /Willi Beetz
Attn: Returns
Hambruecker Landstrasse 8
68753 Waghaeusel - Wiesental
Germany
Phone: +49-7243-602-***/Fax: +49-7243-602-182
E-mail: returns_calce@agilent.com
Product # ________________ Serial #______________________ Product #________________Serial #________________
Product # ________________Serial #______________________ Product #________________Serial #________________
Date: ________________
Returns Credit Number: ________________
Sales Order Number: ________________
Name: ____________________________________________
Company: ___________________________________________
Address: ____________________________________________________________________________________________________
City/State: _________________________________________
Country/Postal Code:__________________________________
Phone: ____________________________________________
Fax: ________________________________________________
A. Please state reason for the return:
Shipment Error: ___________________________________________________________________________________________
OP Error: ________________________________________________________________________________________________
Defective: ________________________________________________________________________________________________
Wrong Labelling: __________________________________________________________________________________________
Duplicate Order: ___________________________________________________________________________________________
Customer Error: ___________________________________________________________________________________________
Warranty Replacement: _____________________________________________________________________________________
Damaged: ________________________________________________________________________________________________
By: Carrier
Forwarder
Customer
Other ___________________________________________________
Other: ___________________________________________________________________________________________________
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B. To protect our employees from exposure to various hazards, you MUST answer the following to the best of your ability.
1. Check if unit has unit been: Powered up? Injection made? (if no on both, skip questions and sign on bottom)
2. Is there any possibility of internal or external contamination on this equipment from any of the following?
YES NO
Blood, body fluids ( e.g. urine, secretions), pathological specimens
YES NO
Infectious substances or other bioagents (e.g. proteins, enzymes, antibodies).
YES NO
Regulated medical wastes
YES NO
Radioactive isotopes are used in the area. Detail type (ECD, isotopic labels, etc.) and activity in microcuries:
_____________________________________________________________________________________________________________
YES NO
Chemicals or substances that are hazardous to health
YES NO
Biodegradable material that could become hazardous
YES NO
Other hazards: ________________________________________________________________________________
3. If you circles YES to any of the above:
a. Specifically describe where (on or in) the instrument/part there might be any residual contamination (for example, blood spill on the top
surface)______________________________________________________________________________________________________
b. Provide details of these hazards. Include names, material safety data sheets (MSDS) and contaminants, where possible.
____________________________________________________________________________________________________________
c. Describe your method of decontamination, if performed. Attach procedure ______________________________________________
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I declare that the information is true and complete to the best of my knowledge and belief.**
Authorized Signature: ________________________________
Date: ___________________________________________
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*If additional decontamination is required, you may be responsible for costs incurred to make the product safe for servicing; Shipment of equipment may fall under
other transportation regulations; All applicable regulations must be followed when returning equipment.
**Agilent reserves the right to reject all returns, upon inspection.