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STERIS AST Forms
SRR Form
STERIS AST FormsSTERIS AST Forms

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    STERIS AST Special Radiation Request Form

    SRR Form

    When completing this form, every field must be completed. If any field is not applicable, it shall be noted with “N/A”. Incomplete forms will result in potential delays in processing.

    1Customer Information
    2Product Information
    3Return Shipping Instructions
    4Assignment of Responsibility
    • STEP 1: Customer Information

      Fill in the fields below. Once you are finished click the blue next section button at the bottom of the page to go to the next section
    • Optional
      Note: Additional charges may apply
    • STEP 2: Product Information

      Fill in the fields below. Once you are finished click the blue next section button at the bottom of the page to go to the next section
    • Product Code (or Product Description)Lot Number# of CasesOpen box & remove contents prior to processing? Y/NMinimum Dose (kGy)Maximum Dose (kGy) 
      To add a new row, click the plus sign at the end of the first row. To remove a row once added, click the minus sign at the end of the row you wish to remove.
      Only one dose range permitted per special radiation request
      Check here if any of the above product codes are mixed-density material.
      (If Yes, a Non-Sterile Shipping Agreement must be in place before submitting material for processing (Not applicable for product processed and distributed in Canada). Contact the processing facility if agreement is needed.
      Certificate of Processing and Dosimetry Record will be provided, note in special instructions if additional documentation needed.
    • When selecting this option please download and email the attached form

      Medical Device Form
    • When selecting this option please download and email the attached form

      Animal Food Form
    • When selecting this option please download and email the attached form

      API Form
    • When selecting this option please download and email the attached form

      Pharmaceutical Form
    • If checked, STERIS management: Contact the Senior Radiation Safety Manager
    • If checked, MSDS must be provided before processing
    • If checked, product cannot be augmented without Customer approval which may cause delays in processing and shipping.
    • STEP 3: Return Shipping Instructions

      Fill in the fields below. Once you are finished click the blue next section button at the bottom of the page to go to the next section
    • Optional
    • STEP 4: Assignment of Responsibility

      This is the final section. Once you are ready hit the green submit button at the bottom of the form and your request will be sent for processing

    • RESPONSIBILITY

      Assignment

      I. GENERAL
      1. Responsible for use of radiation sensitive labels (false negatives, false positives, placement)

      2. Ensure that special instructions are provided for sample processing placement requirements, product temperature sensitivity requirements, and time sensitive requirements for product capable of supporting microbial growth.

      CUSTOMER

      1. Responsible for use of radiation sensitive labels (false negatives, false positives, placement)

      CUSTOMER

      1. Responsible for use of radiation sensitive labels (false negatives, false positives, placement)

      2. Determine if 21CFR 801.150 for Device, or 21CFR 201.150 for Drugs are applicable to processing of the Products.

      CUSTOMER

      1. Ensure that Products may be processed without violating any governmental regulations.

      CUSTOMER

      1. Assure compliance with any and all federal, state and local labeling or "right to know" laws, Including but not limited to, California's Safe Drinking Water and Toxic Enforcement Act of 1986, if applicable.

      CUSTOMER

      1. Notification of intent to recall product processed at STERIS.

      CUSTOMER

      1. Medical Device Manufacturer provision of FDA product listing information to FDA and STERIS in accordance with 21 CFR, Part 807 

      CUSTOMER

      1. Product listing with FDA in accordance with 21 CFR, Part 807

      STERIS

      1. Subject to STERIS's reasonable confidentiality obligations, allow customer access to the processing facility, upon reasonable notice, during normal business hours for the purpose of conducting Quality System audits, at customer’s expense, related to the processing of customer products.

      STERIS

      1. Perform periodic internal audits according to Quality System. A record of the audit shall be maintained on file.

      STERIS

      1. Allow the U.S. FDA to inspect its facilities as stated in section 704(a) of the Food, Drug and Cosmetic Act and 21 CFR Part 200.10, if applicable.

      STERIS

      II. PROCESS CONTROL

      1. Ensure that the CUSTOMER process specifications are achieved and that documentation for each load is reviewed by a Qualified STERIS Representative before release to CUSTOMER.

      STERIS

      1. Notify CUSTOMER of equipment changes in accordance with STERIS’s established change control procedure.

      STERIS

      1. Evaluate STERIS’s equipment change control notification and communicate action to STERIS, as needed.

      CUSTOMER

      III. MATERIAL HANDLING AND DOCUMENTATION REQUIREMENTS FOR INCOMING PRODUCT TO STERIS

      1. Ensure proper shipment of Product to STERIS to include Labeling, Packing List, Purchase Order and Process Specifications (or completed Special Radiation Request).

      CUSTOMER

      1. Provide proper labeling and identification for all products / samples. Packing slip shall match product code on case label. All exceptions will be communicated in advance of shipment to STERIS.

      CUSTOMER

      1. Resolve damaged goods disposition.

      CUSTOMER

      1. Complete Non-Sterile Shipping Agreement, if applicable.

      CUSTOMER

      1. Confirm that documentation to satisfy 21CFR 801.150 for Device, or 21CFR 201.150 for Drugs is provided, if applicable.

      STERIS

      1. Receive and record incoming product samples to STERIS.

      STERIS

      1. Resolve count discrepancies with CUSTOMER.

      STERIS

      IV. PROCESSING

      1. Carry out processing parameters in accordance with CUSTOMER specifications.

      STERIS

      1. Control the flow of Products to and from the processing area to prevent mixing of processed and non-processed Products.

      STERIS

      1. Installation, qualification, operation and maintenance of equipment, calibration of process monitoring equipment and training of operating personnel.

      STERIS

      1. Determine the compatibility of Products and packaging with the processing procedures and for determining the appropriate processing modality and parameters. All tests related to the processing of the Products. Ultimate and full responsibility for Products release into commercial distribution, including labeling of Products as sterile. All tests related to assessing the final sterility assurance of the products.

      CUSTOMER

      1. Ensure specifications are provided in writing to STERIS for all special instructions or special handling requirements prior to processing product.

      CUSTOMER

      1. Prior to product being processed, notify STERIS if products are flammable, corrosive, combustible, bio-hazardous, bio-active, or hazardous in any way. In addition, an MSDS will be provided for all products, prior to processing, if they are flammable, corrosive, combustible, bio-hazardous, bio-active, or hazardous in any way.

      CUSTOMER

      1. Assure that any changes to the manufacturing, packaging, and the product are evaluated for their impact on the continued validation of the processing parameters.

      CUSTOMER

      1. Prior to product being shipped to STERIS, notify STERIS when there is a change to product case size, weight, or any other change to the product that could in any way change processing parameters.

      CUSTOMER

      V. PROCESSING NONCONFORMITIES

      1. Determine and notify CUSTOMER thereof.

      STERIS

      1. Determine corrective action and notify CUSTOMER thereof.

      STERIS

      1. Implement corrective action.

      STERIS

      VI. SHIPMENT FROM STERIS

      1. Document number and destination of samples sent for testing from STERIS on the STERIS Packing List. (If applicable)

      STERIS

      1. Generate a Certificate of Processing and a Packing List for each shipment.

      STERIS

      1. Document the quantity of Product from STERIS on the Certificate of Processing. Any discrepancies will be resolved with CUSTOMER prior to shipment.

      STERIS

      1. Label all processed Product as “Processed” or similar, with no reference to the Product being sterile.

      STERIS

    • Liability shall be limited to the lesser of the manufacturing cost of the products or ten (10) times the processing charge. The Assignment of Responsibilities, attached as Exhibit A and incorporated herein by reference, shall apply to all processing services rendered pursuant to this agreement. Notwithstanding the foregoing, the terms and conditions of a Processing Agreement between STERIS and Customer shall take precedence over this Special Radiation Request agreement in the event of a conflict.
    • Clear Signature
    • This field is for validation purposes and should be left unchanged.
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