Lab Signage Requirements Form

410 Campus Drive East Tuscaloosa, Alabama 35487 (205) 348-5905 FAX: (205) 348-7773 LAB SIGNAGE REQUIREMENTS FORM

Directions: . Save this document using the nomenclature: e.g., NOTE: if lab has two room numbers, please include both when naming the document Example: < LS-SERC-ME-ASHFORD -1234-1235> . If you have multiple labs (in the same building or multiple buildings), complete one form per lab . Complete all information in Section 1 electronically o Use the mouse, tab, or scroll - page up/down arrows will not work o Enter N/A if a prompt does not apply

SECTION 1  THIS SECTION COMPLETED BY THE PI OR DESIGNEE 

LAB INFORMATION:

Building: Room/Lab # # of ext./corridor doors # of internal lab doors:

Department:

Dept. Head/Chair Office building: Office #:

Is this lab shared Yes If Yes, are the hazards used by each Yes* by more than one No PI exactly the same? No ** PI? Unknown ** * If Yes, only one form must be completed for the lab, if possible. Please list all PIs below **If No or Unknown, each PI must complete a form for their area Principle Investigator (PI): Date Form Completed:

EMERGENCY CONTACT INFORMATION Name of person who will respond - off hours - to an alarm in the lab (must have a minimum of 2) Shared labs must determine who will respond for the lab as a whole Name: Home Phone #: Cell Phone #: Name: Home Phone #: Cell Phone #: Name: Home Phone #: Cell Phone #:

UA-EHS page 1 of 5 LAB SIGNAGE REQUIREMENTS FORM

EQUIPMENT CURRENTLY USED IN LAB (check all that apply): Lasers Yes No Quantity 3B 4 Other/Unknown (Describe) Particle Accelerator/X- Yes No Ray/Fluoroscope, E.M. (ionizing radiation equipment) If yes, list types NMR/MRI/Super Conducting Magnets Yes No If yes, list types: UV Lights - Metal Halide, High pressure Yes No xenon, Mercury Vapor, or other ‘blue light’ producing lamp High Voltage Devices Yes No If yes, list

Cryogenic Gas - bulk tank or hard-piped Yes No If yes, list Other/explain:

TYPES OF AGENTS USED IN LAB (check all that apply): Radioactive Materials Yes No

Authorized Radiation Investigator (ARI): Name: (This information must be provided if Radioactive Materials Yes box is checked)

Biohazard Materials Yes* No

*If Biohazard Materials Yes box is checked, indicate the type of materials & the containment needs Type of biohazrd Containment Needs Human BBP BSL 2 BSL 3

Non-Human primate BSL 2 BSL 3 tissue

Other animal tissues, cells, BSL 2 BSL 3 blood

Recombinant DNA BSL 2 BSL 3 Synthetic DNA BSL 2 BSL 3

Viral Vector BSL 2 BSL 3 Transgenic Animals BSL 2 BSL 3

Bio-nano Particles BSL 2 BSL 3 Prions BSL 2 BSL 3

Parasites BSL 2 BSL 3 Plants BSL 2 BSL 3

UA-EHS Revision Date: 3-Apr-18 page 2 of 5 LAB SIGNAGE REQUIREMENTS FORM

Insects BSL 2 BSL 3 Bacteria BSL 2 BSL 3

Virus BSL 2 BSL 3 Fungus BSL 2 BSL 3

USDA-regulated agents / BSL 2 BSL 3 animals

Other/explain: BSL 2 BSL 3 CDC Select Agents

Chemical Hazards List only if these select chemicals are not currently included in our Cispro inventory system. You may attach a separate sheet if needed.

Corrosives Yes No List:

Hydrofluoric Acid Yes No

Perchloric Acid Yes No Known, potential, or Yes No List: reasonably assumed to be Human Carcinogens

Flammable Materials Yes No Type: solid liquid gas

Reproductive or Yes No List: Mutagenic Hazards

Teratogens Yes No List:

Hepatotoxin Yes No List:

Oxidizer Yes No List:

Compressed Gas Yes No List: Cylinders

Lecture Bottles Yes No List:

Mercury Compounds Yes No List:

Toxic – LD <50 mg/kg Yes No List: (e.g., cholinesterase Inhibitors)

Explosives Yes No List:

Water Reactive Yes No List: Compounds

Comments:

MINIMUM PPE REQUIRED FOR ENTRY (check all that apply): Gloves at all times Yes No Type Nitrile Butyl Required: Latex Other Non specific

Lab coat at all times Yes No Entry (if a lab coat Type standard is required for entry Required: flame resistant into the lab) Gloves when working Yes No Type Nitrile Butyl Required: Latex Cryo Thermal Other

Lab Coat when Yes No Type Required: standard working flame resistant

Face/Eye Protection Required at all times while in the lab

Type Required: Minimum Safety Glass with side shields Chemical Goggles Face Shield Closed-Toe Shoes Yes

Hearing Protection Yes No List/Explain

Respiratory Protection Yes No List/Explain

Shoe Covers Yes No Sleeve Covers Yes No

Tyvek suit Yes No Other/explain:

Comments:

ENGINEERING / ADMINISTRATIVE CONTROLS (check all that apply):

Autoclave Yes No Biosafety Cabinet Yes No Date of Certification available on sharepoint website

Safety Shower – Yes No inside lab

Safety Shower – Yes No outside lab

Eyewash Station – Yes No inside lab

Eyewash Station – Yes No outside lab

Flammable Liquid Yes No Storage Cabinet

Chemical Fume Hood Yes No Date of Certification available on sharepoint website Perchloric fume hood Yes No

Glove Box Yes No Sink for hand washing Yes No

Snorkel Exhaust Yes No Restricted Access Yes No

Restricted Access requires: Sign-in Log Yes No

Card Key Yes No Signage Yes No Explain:

Ventilated Powders Yes No Cabinet SPECIAL INTEREST MATERIALS AND/OR CHEMICALS If you are uncertain of the categorization of your chemicals please contact EHS

1. Are you using OSHA REGULATED CHEMICALS? Yes No

2. Are you using Department of Homeland Security Chemicals of Interest? Yes No 3. Are you using materials regulated by the Drug Enforcement Administration? (drugs or chemicals) Yes No

UA-EHS Revision Date: 3-Apr-18 page 5 of 5