Laboratory Equipment Owner Decontamination

Complete this form before you service or move your equipment. Contact EHS at (734) 647-1143 for questions about decontamination or completing this form.

Complete and submit this form two (2) weeks prior to the move or service date for a biological safety cabinet.

Call Radiation Safety Service at (734) 647-1143 to schedule a survey of equipment used with radioactive materials.

Contact Information

Laboratory Director *

Department *

Laboratory Manager *

Contact Phone Number *

Building *

Room Number *

Equipment Information

Equipment Type/Model *

Serial Number *

Select all that apply *

Service

Move

Disposal

Service to be performed

If the equipment is moving, provide date of move and new location

Disposal

Biological Safety Cabinet (BSC)

Biological Safety Cabinets (BSC) cannot be moved or serviced without authorization from the U-M Biosafety Officer (BSO). Biological Safety will sign this form after the BSC has been decontaminated.

Is the equipment a Biological Safety Cabinet (BSC)? *

Yes

Describe materials used inside BSC, e.g., specific species of cell line, bio agents, human materials, hazardous drugs or engineered nano-materials, etc. *

Release Date

Initials

Radioactive Materials

Were radioactive materials used or stored in the equipment? *

Yes

Sign this form below to verify that RSS has cleared the equipment for release.

Certification of Decontamination

I certify that the above laboratory equipment has been thoroughly cleaned and decontaminated of all chemical, biological, and radioactive contaminants.

Name

Signature

Date

If you are human, leave this field blank.

Click Submit to start the BSC authorization process.

Click Print, sign form, and attach to the equipment.

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