Fillable Decontaminationrecord

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Decontaminationrecord

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File type: PDF

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Record of
Decontamination
Request to Discard or Relocate
Equip
men
t
Department:
Date:
Responsible Party
State ID:
Type of Equipment:
Model #
Manufacturer’s Name:
Serial Number:
Current Location:
Requesting:
Disposal:
Relocation:
Move to:
Other:
(E xp la in ):
Equipment Contamination Information:
This equipment may have been contaminated with:
Type of Hazardous Agent:
List Agents if known
Disinfection/Cleaning Information:
Date: Per
son:
Hazardous Chemical:
Yes
No
Infectious Agents:
Yes
No
Radioactive Material:
Yes
No
None of the Above:
Comments:
Comments:
The above stated equipment has been decontaminated and/or cleaned as necessary for safe removal.
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Decontaminationrecord

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Completed 1 March 2020

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