Laboratory Decommissioning Form "*" indicates required fields Name:* First Last Email:* Enter Email Confirm 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:* Month Day Year Reason for Departure (If Applicable):Will Any Active Research Remain in the Space After Departure?*Type of Laboratory - Check ALL That Apply:* Chemical Biological Radiation Shop Other Fume Hood and Laboratory EquipmentHave 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 ChemicalsChemicals (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 (COIs) 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 Material 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 a Brief Explanation:BiologicalsBiologicals Present in Laboratory?* Yes No Has the Biological Safety Officer Been Informed of the Decommissioning Plan?* Yes No Has a Waste Request Been Submitted for Collection of Biologicals?* Yes No If "No", Provide a Brief ExplanationWill 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 the Person(s) Receiving Biological Components:If UA, State the Type and Number:If Another Institution, Provide the Name of Institution: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 a Brief Explanation:RadiationRadioisotopes/Radiation Present in the 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 a Brief Explanation:Will Any Radioisotopes/Radiation Equipment Remain in the Space After Decommissioning?* Yes No If "Yes", Provide a 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 the Person(s) Receiving Radioisotopes/Radiation Equipment:If Another Institution, Provide Name of Institution: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 a Brief Explanation:LasersLasers 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? Yes No Will Any Lasers Remain in the Space After Decommissioning? Yes No If "Yes", Provide a Brief Explanation:Will Any Lasers Be Transferred to Another Research Group at UA or Another Institution? UA Another Institution If UA, Please Provide the Name(s) of the Person(s) Receiving Lasers:If Another Institution, Please Provide Institution Name:If Another Institution, Has MTA Information Been Discussed?EmailThis field is for validation purposes and should be left unchanged.
