OAKLAND UNIVERSITY ENVIRONMENTAL HEALTH & SAFETY LABORATORY EQUIPMENT SAFETY

Complete this form for all equipment released for surplus, disposal or repairs. Send completed form to Laboratory Compliance Manger by campus mail to the GHC-APT address or fax (4376). EH&S will provide instruction on the removal of warning labels once equipment has been approved for release. A copy of this approved release form must be affixed to the instrument prior to any transfer or disposal.

Building:

Room:

Description of Equipment:

Manufacturer:

Model #:

Serial #:

OU property tag # (if affixed):

Equipment destination (Please circle):

(Property Office) (Disposal) (Repairs) (Other:______________________)

Equipment Use

(Select all that apply)

This equipment has never been used with any Chemicals, Infectious materials (including blood or human tissues), Radioactive material, and does not present any known hazards.

Chemical Use:

List Chemicals or chemical classes used:___________________________

(Example: mercury, lead, heavy metals, etc.)

Biological Agents:

List Biological Agents Used:

Radioactive Materials:

List Isotopes Used:

Radiation Safety clearance signature: Date:

Other Hazards (Ex: Nanoparticles, electrical, mechanical or stored energy hazards)

Explain:

Intrinsic Hazards

Please list any hazards or hazardous materials known to be built into the device such as mercury switches, batteries, high voltage capacitors, etc.:

Decontamination or Hazard Removal Information

List appropriate decontaminant used:

Briefly describe process used to decon or remove hazard:

Person responsible for hazard removal :

Date:

Certification

Signature of Principal Investigator or Laboratory Supervisor.

( Print Name) (Signature)

EH&S Approval

EH&S Reviewer:

( Print Name) (Signature)

Date:

Phone:

Comments: