<p> 410 Campus Drive East Tuscaloosa, Alabama 35487 (205) 348-5905 FAX: (205) 348-7773 LAB SIGNAGE REQUIREMENTS FORM</p><p>Directions: . Save this document using the nomenclature: <LS-Building-Dept-PI-lab#> e.g., <LS-SERC-ME-ASHFORD-1234> 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</p><p>SECTION 1  THIS SECTION COMPLETED BY THE PI OR DESIGNEE </p><p>LAB INFORMATION:</p><p>Building: Room/Lab # # of ext./corridor doors # of internal lab doors: </p><p>Department: </p><p>Dept. Head/Chair Office building: Office #: </p><p>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:</p><p>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 #: </p><p>UA-EHS page 1 of 5 LAB SIGNAGE REQUIREMENTS FORM</p><p>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 </p><p>Cryogenic Gas - bulk tank or hard-piped Yes No If yes, list Other/explain:</p><p>TYPES OF AGENTS USED IN LAB (check all that apply): Radioactive Materials Yes No</p><p>Authorized Radiation Investigator (ARI): Name: (This information must be provided if Radioactive Materials Yes box is checked)</p><p>Biohazard Materials Yes* No</p><p>*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</p><p>Non-Human primate BSL 2 BSL 3 tissue</p><p>Other animal tissues, cells, BSL 2 BSL 3 blood</p><p>Recombinant DNA BSL 2 BSL 3 Synthetic DNA BSL 2 BSL 3</p><p>Viral Vector BSL 2 BSL 3 Transgenic Animals BSL 2 BSL 3</p><p>Bio-nano Particles BSL 2 BSL 3 Prions BSL 2 BSL 3</p><p>Parasites BSL 2 BSL 3 Plants BSL 2 BSL 3</p><p>UA-EHS Revision Date: 3-Apr-18 page 2 of 5 LAB SIGNAGE REQUIREMENTS FORM</p><p>Insects BSL 2 BSL 3 Bacteria BSL 2 BSL 3</p><p>Virus BSL 2 BSL 3 Fungus BSL 2 BSL 3</p><p>USDA-regulated agents / BSL 2 BSL 3 animals</p><p>Other/explain: BSL 2 BSL 3 CDC Select Agents </p><p>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. </p><p>Corrosives Yes No List: </p><p>Hydrofluoric Acid Yes No</p><p>Perchloric Acid Yes No Known, potential, or Yes No List: reasonably assumed to be Human Carcinogens</p><p>Flammable Materials Yes No Type: solid liquid gas</p><p>Reproductive or Yes No List: Mutagenic Hazards </p><p>Teratogens Yes No List: </p><p>Hepatotoxin Yes No List: </p><p>Oxidizer Yes No List: </p><p>Compressed Gas Yes No List: Cylinders</p><p>Lecture Bottles Yes No List: </p><p>Mercury Compounds Yes No List: </p><p>Toxic – LD <50 mg/kg Yes No List: (e.g., cholinesterase Inhibitors)</p><p>Explosives Yes No List: </p><p>Water Reactive Yes No List: Compounds</p><p>Comments: </p><p>UA-EHS Revision Date: 3-Apr-18 page 3 of 5 LAB SIGNAGE REQUIREMENTS FORM</p><p>MINIMUM PPE REQUIRED FOR ENTRY (check all that apply): Gloves at all times Yes No Type Nitrile Butyl Required: Latex Other Non specific</p><p>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</p><p>Lab Coat when Yes No Type Required: standard working flame resistant</p><p>Face/Eye Protection Required at all times while in the lab</p><p>Type Required: Minimum Safety Glass with side shields Chemical Goggles Face Shield Closed-Toe Shoes Yes</p><p>Hearing Protection Yes No List/Explain </p><p>Respiratory Protection Yes No List/Explain </p><p>Shoe Covers Yes No Sleeve Covers Yes No</p><p>Tyvek suit Yes No Other/explain: </p><p>Comments: </p><p>ENGINEERING / ADMINISTRATIVE CONTROLS (check all that apply):</p><p>Autoclave Yes No Biosafety Cabinet Yes No Date of Certification available on sharepoint website</p><p>Safety Shower – Yes No inside lab</p><p>Safety Shower – Yes No outside lab</p><p>Eyewash Station – Yes No inside lab</p><p>Eyewash Station – Yes No outside lab</p><p>Flammable Liquid Yes No Storage Cabinet</p><p>UA-EHS Revision Date: 3-Apr-18 page 4 of 5 LAB SIGNAGE REQUIREMENTS FORM</p><p>Chemical Fume Hood Yes No Date of Certification available on sharepoint website Perchloric fume hood Yes No</p><p>Glove Box Yes No Sink for hand washing Yes No</p><p>Snorkel Exhaust Yes No Restricted Access Yes No</p><p>Restricted Access requires: Sign-in Log Yes No</p><p>Card Key Yes No Signage Yes No Explain: </p><p>Ventilated Powders Yes No Cabinet SPECIAL INTEREST MATERIALS AND/OR CHEMICALS If you are uncertain of the categorization of your chemicals please contact EHS</p><p>1. Are you using OSHA REGULATED CHEMICALS? Yes No</p><p>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</p><p>UA-EHS Revision Date: 3-Apr-18 page 5 of 5</p>