Laboratory Decommissioning Form – Environmental Health & Safety

General Information

Name

First

Last

Email

Building:

Room Number:

Department:

Department Chair Name and Contact Information:

Responsible Researcher/Manager of Space:

Previous User of Space (if available):

Date of Departure from Space:

Reason for Departure (if applicable):

Will any active research remain in the space after departure?

If yes, who will be supervising the activities and personnel remaining in the space?

Type of laboratory - Check ALL that apply

Fume Hood and Laboratory Equipment

Have decommissioning/equipment hazard tags been placed on each piece of equipment for decommissioning?

Yes
No

If no, please provide a brief explanation

Has EHS been notified of equipment for decommissioning?

Yes
No

Number of fume hoods (if applicable)

Size of fume hoods

Equipment in laboratory for decommissioning (put multiple if more than 5)

Have decommissioning/equipment hazard tags been placed on fume hoods?

Yes
No

If no, please provide a brief explanation

Has EHS been notified of fume hoods for decommissioning?

Yes
No

Chemicals

Chemicals (including resins, paints, etc.) present in the laboratory?

Yes
No

Has a waste request been submitted for collection of chemicals?

Yes
No

If no, please provide a brief explanation

Will any chemicals remain in the space after decommissioning?

Yes
No

List (if applicable) any federally regulated/chemicals of interest remaining in the space:

Will any chemicals be transferred to another research group at UA or another institution?

UA
Another Institution

If UA, provide the name(s) of person(s) receiving chemicals:

If another institution, provide institution name:

List (if applicable) any federally regulated/chemicals of interest (COIs) being transferred

If yes, state type and estimated number:

If transferring chemicals to another institution, has Materials Transfer Agreement (MTA) information been discussed?

Yes
No

Explain:

Are there any chemicals or containers in the lab for which the chemical composition is unknown?

Yes
No

If yes, provide brief explanation:

Biologicals

Biologicals present in laboratory?

Yes
No

Has the Biological Safety Officer been informed of the decommissioning plan?

Has a waste request been submitted for collection of biologicals?

Yes
No

If no, provide brief explanation:

Will any biological components remain in the space after decommissioning?

Yes
No

Will any biological components be transferred to another research group at UA or another institution?

UA
Another Institution

If UA, provide the name(s) of person(s) receiving biological components:

If UA, state type and number:

If another institution, provide institution name:

If another institution, has MTA information been discussed?

Are there any biological materials in the lab for which the composition is unknown

Yes
No

If yes, provide brief explanation:

Radiation

Radioisotopes/radiation present in lab?

Yes
No

Identify the sublicensee for the radiation present:

Has the Radiation Safety Officer been informed of the decommissioning plan?

Has a waste request been submitted for collection of radiological materials and items?

Yes
No

If no, provide explanation:

Will any radioisotopes/radiation equipment remain in the space after decommissioning?

Yes
No

If yes, provide brief explanation:

Will any radioisotopes/radiation equipment be transferred to another research group at UA or another institution?

UA
Another Institution

If UA, provide the name(s) of person(s) receiving radioisotopes/radiation equipment:

If another institution, provide institution name:

If another institution, has MTA information been discussed?

Are there any radioisotopes/radiation materials, items, or instruments in the lab for which the radioisotopic nature is unknown?

Yes
No

If yes, provide brief explanation:

Lasers

Lasers present in the laboratory?

Yes
No

If yes, provide laser class and any other additional information about the laser:

Identify the responsible party for the laser:

Has a decommissioning/equipment tag been completed?

Yes
No

Has EHS been notified?

Will any lasers remain in the space after decommissioning?

Yes
No

If yes, provide brief description:

Will any lasers be transferred to another research group at UA or another institution?

UA
Another Institution

If UA, provide the name(s) of person(s) receiving laser/lasers:

If another institution, provide institution name:

If another institution, has MTA information been discussed?