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Laboratory Decommissioning

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 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 (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:

Biologicals

Biologicals 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 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 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:

Radiation

Radioisotopes/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:

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?

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?

Phone

This field is for validation purposes and should be left unchanged.

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