This form must be completed and attached to laboratory equipment that is to be salvaged, relocated or disposed of prior to removal from or abandonment of the laboratory.


To the best of my knowledge the following piece of equipment:


___________________________________________________   _______________

Manufacturer,Model#,Serial#                                                                                                  Inventory#


        Has never been used with radioactive materials, hazardous chemicals or biological agents.


____________________________                                                                 ________________

Signature                                                                                                                     Date

____________________________     ________________                            ________________

Printed Name                                                   Title                                                      Department


      has been used with the following materials:

                         Radioactive material(s)*




                              Hazardous Chemical(s)**


                          Name High Risk Chemical(s)


                              Biological Agent(s)



The above named equipment has been cleaned with

__________________________________________, which is suitable

Describe process and agent used


for deactivating/removing the hazardous materials used with/in this equipment.


Date of decontamination


*Decontamination must be confirmed by wipe test.

**See Safety Manual, Chapter 8, High Risk Chemicals.


________________________                                                           ________________

Signature                                                                                             Date

________________________           _______________                  ________________

Printed Name                                      Title                                         Department          



How to complete the form:


1.       Notify Health & Safety Service \ Biological & Chemical Safety Program at X21781 of any moves regarding chemical fume hoods or biological safety cabinets. (Tissue Hoods) This equipment is marked with a three digit OEHS ID# or HSS ID#.


2.        Identify the equipment by providing the Manufacturer, Model #, Serial # and the UTMB Inventory #.


3.        Check the appropriate box indicating whether of not the equipment has been used with radioactive materials, hazardous chemicals or biological materials.


4.        If the equipment was not used with hazardous chemicals or biological and or radioactive materials, sign and date the form. Attach the completed form to the equipment. The equipment is then ready for transport.


5.        If the equipment was used with the hazardous materials, indicate which type of material by marking the appropriate box.


6.        For usage with radioactive materials, list the radionuclide(s) used. The equipment must be wipe tested. The wipe tests can be done by HSS or performed by personnel form the lab and the wipes brought to the HSS \ Radiation Safety for counting. HSS/Radiation Safety will inform the lab of the results. If the equipment is free of contamination, document o the form the date of the clearance was given and the name of the HSS\Radiation Safety personnel issuing the clearance. Sign and date the form and attach to the equipment.


7.        For usage with hazardous chemicals, list the name of the chemical(s) and clean with the appropriate compound. Document the cleanup date and the cleaning compound used. Sign and date the form and attach to the equipment.


8.        For usage with biological agents, list the agent(s) used. Clean with a suitable disinfectant, document date and disinfectant used. Sign and date the form and attach to the equipment.