DECONTAMINATION CERTIFICATE
(Care Home Facilities)

Name of Care Home:

Equipment being sent to:

Description of Equipment:

Model\Serial\batch number:

Tick one box

This equipment HAS NOT been in contact with blood/fluids. It has been cleaned with detergent and water.

A	

This equipment HAS been exposed to blood/body substance and has been cleaned with detergent and water.

B

This equipment cannot be decontaminated because:

C

Please follow universal/standard precautions when handling this equipment.
I declare I have taken all reasonable steps to ensure the accuracy of the above information
Name (printed): ________________________    Signature: _______________________      
Date: __/__/__                                                               Tel no: _________________________    
Attach completed certificate to the item of equipment and retain a copy for your own records.