UNCONTROLLED COPY: Updated 5/6/2024

Equipment Decontamination and Data Removal Certification

Customers in the EU are advised to visit Revvity’s public website and review Revvity’s Compliance to Environmental Directives prior to discarding electrical and electronic equipment
originally manufactured by Revvity (RVTY).
INSTRUCTIONS: This form must be used whenever customer-purchased/owned equipment (instruments, materials, parts, etc…) is shipped to RVTY or Revvity’s business partners forrepair, refurbishing, trade-in, replacement, recycling, disposal, or credit. Any equipment that has been used by a customer or located in an area where chemical, biological, orradioactive materials are/were handled must be assessed and, if necessary, decontaminated before it may be shipped from a customer’s site. The customer must provide truthful,accurate information on this form and certify that the equipment is free of potentially hazardous contamination prior to shipping. Furthermore, all potentially sensitive/confidential
data or information must be removed from all equipment prior to shipping or transfer.
Prior to shipping any used equipment to a destination facility, an authorized employee of the customer must complete/sign this form. RVTY field staff may complete/sign this form onbehalf of the customer if the equipment is new, unused, and contains no sensitive/confidential information. A physical copy of this form shall be sent with the returned equipment(placed on the outside of the shipping container, in a “shipping docs” bag/envelope).
Certain destination facilities may have additional requirements for customers to submit this form for review and approval prior to shipping returned equipment. Contact RVTY Customer
Care/Service for details.

EQUIPMENT DETAILSINSTRUMENT NAME / MODEL / TYPEINSTRUMENT SERIAL #REASON FOR RETURN
ADDITIONAL DETAILSPART #Select from Dropdown(ex. attachment references, quantity of items, F1 notification #,RMA #, sale order #, PO #, service alert details, etc…)
NOTE: RMA # is MANDATORY for US Revvity factory returns/repairs

EQUIPMENT USE/DECONTAMINATION DECLARATION☐ NEW, UNUSED EQUIPMENT - Customer/user certifies that returned instruments/parts are new and have never been placed into service.
☐ USED EQUIPMENT (NO CONTAMINATION) - Customer/user certifies that returned instruments/parts are used, but did not come intocontact with a) biological substances; b) radioactive materials; or c) potentially hazardous chemicals☐ USED EQUIPMENT (POTENTIAL BIOLOGICAL CONTAMINATION)1 - Customer/user discloses that instruments/parts may have come incontact with biological, biohazardous, or infectious agents.
Provide a detailed description ofbiological agents:
Describe disinfection materials andmethods used:☐ USED EQUIPMENT (POTENTIAL RADIATION CONTAMINATION)2 - Customer/user discloses that the instruments/parts may have come incontact with radioactive materials.
Provide a detailed description ofradioactive materials:
Describe decontamination or sourceremoval details:☐ USED EQUIPMENT (POTENTIAL CHEMICAL CONTAMINATION)3 - Customer/user discloses that the instruments/parts may have come incontact with potentially hazardous chemicals.
Provide a detailed description of
hazardous chemical contaminants:
Describe decontamination materials
and methods used:

1 Equipment used in BSL-4 laboratories cannot be shipped/returned.

2 Customer must provide radiation survey results that demonstrate that the instrument is free of radioactive contamination. Equipment with detectable radiation

above background levels cannot be shipped/returned. Customers who wish to return, recycle, or dispose of equipment that contains or once-contained
radioactive materials (i.e. sealed sources) must contact RVTY and request instructions for how to prepare the equipment/materials prior to shipment.
3 Equipment that may have come in contact with chemical warfare agents, dioxins, or explosive compounds cannot be shipped/returned.

CERTIFICATIONI certify that to the best of my knowledge and belief that all the information on this form is correct and that the returned equipment described above is free of potentially hazardous biological,radiological, or chemical contamination that may harm human health or the environment. I accept responsibility for the decontamination and cleaning activities described on this form. I also
understand that I must provide timely responses to reasonable requests from RVTY or Revvity’s business partners for additional information for how returned equipment has been used anddecontaminated. RVTY (including any of its business groups or business partners) has no obligation to handle, repair, service, recycle, or dispose any product unless adequate information isprovided to ensure the safety of all personnel who may come in contact with the returned/shipped equipment.
Furthermore, I certify to the best of my knowledge and belief the returned equipment contains no potentially sensitive and/or confidential information (including but not limited to personal /customer data). I understand that RVTY (including any of its business groups or business partners) is not responsible for preventing unauthorized retrieval and misuse of sensitive or confidential
information that is retained on or inside returned equipment or instrumentation.

Customer Company Name

Customer Phone #Customer Employee Name (printed)

Customer Employee Title

Customer Employee Signature

Date Signed☐ Check this box if the equipment is verified new and unused and a RVTY employee has signed this form on behalf of the customer.
Name of Destination Facility Staff Member Who
Reviewed and Acknowledged This ReturnDocument Name: 67107
Revision: GFOR INTERNAL USE ONLY
Date of ReviewPage 1CONFIDENTIAL AND PROPRIETARY