Lab Signage Form

Building *

Room/Lab # *

Department *

Department Head/Chair *

Is this lab shared by more than one PI?

YesNo

Principle Investigator (PI)

Phone *

Equipment currently used in the lab *

LasersParticle Accelerator/X-Ray/Fluoroscope, E.M. (ionizing radiation equipment)NMR/MRI/Super Conducting MagnetsUV Lights - Metal Halide, High pressure xenon, Mercury Vapor, or other 'blue light' producing lampHigh Voltage DevicesCryogenic Gas - bulk tank or hard-pipedNoneOther/explain

Types of agents used in the lab *

Radioactive MaterialsBiohazard MaterialsNoneOther

If using biohazard materials, please select type *

Human BBPNon-Human primate tissueOther animal tissues, cells, bloodRecombinant DNASynthetic DNAViral VectorTransgenic AnimalsBio-nano ParticlesPrionsParasitesPlantsInsectsBacteriaVirusFungusUSDA-regulated agents/animalsCDC Select AgentsOtherNone

Chemical Hazards

Please select any chemicals not currently listed in your inventory.CorrosivesHydrofluoric AcidPerchloric AcidKnown, potential, or reasonably assumed to be Human CarcinogensFlammable MaterialsReproductive or Mutagenic HazardsTeratogensHepatotoxinOxidizerCompressed Gas CylindersLecture BottlesMercury CompoundsToxic - LD <50 mg/kg (e.g., cholinesterase inhibitors)ExplosivesWater Reactive Compounds

Minimum PPE Required for Entry *

Gloves at all timesLab coat at all timesGloves when workingLab coat when workingFace/Eye ProtectionClosed-Toe ShoesHearing ProtectionRespiratory ProtectionShoe CoversSleeve CoversTyvek suitOther/explain

What equipment will your research require? *

AutoclaveBiosafety CabinetChemical Fume HoodPerchloric Fume HoodGlove BoxSnorkel ExhaustVentilated Powders CabinetOther

Are you using OSHA Regulated Chemicals?

YesNo

Are you using Department of Homeland Security Chemicals of Interest?

YesNo

Are you using materials regulated by the Drug Enforcement Administration? (drugs or chemicals)

YesNo

Please specify any requested alterations required to this signage (addition or removal of hazard symbols, updated diamond information, etc.) Provide description of changes.

Date this form was completed *

Lab Information

Emergency Contact Information

Special Interest Materials and/or Chemicals

Verification