Fillable EQUIPMENT CLEARANCE FORM - Public University of Maryland (University of Maryland, Baltimore)

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EQUIPMENT CLEARANCE FORM - Public University of Maryland (University of Maryland, Baltimore)

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EQUIPMENT CLEARANCE FORM - Public
University of Maryland Baltimore
Instructions and Form
In order for some types of equipment to be moved, removed, or to undergo maintenance, lab personnel and responsible
parties must first ensure that it has been suitably decontaminated and safe. Complete this form entirely after equipment
has been fully cleaned and decontaminated by lab personnel. Have a signed copy available for movers or property
personnel.
Any equipment that has contained or been exposed to chemical, biological, or radioactive hazards must first be
decontaminated before relocation or disposal. It is the responsibility of the principal investigator to ensure that all areas
have been decontaminated by personnel using the appropriate PPE and that the health and safety of the University’s
students, staff, and outside contractors are protected.
Chemical Hazards: Wipe surfaces and equipment that have come in contact with toxic/hazardous chemicals with a
warm solution of soap and water. This may include fumehoods (inside and out), bench tops, floors, refrigerators and
sinks.
Biological Hazards: Any surface with which a biological hazard has come into contact must be decontaminated using an
appropriate agent, such as a 1:10 dilution of household bleach in water (5.25% sodium hypochlorite) left on the surface
for 15 minutes, then wiped off, or Wescodyne following manufacturer’s recommendations. The surface must then be
wiped with a 70% ethanol solution to remove residue. The principal investigator is responsible for verifying that sodium
hypochlorite or Wescodyne is the appropriate substance to inactivate the hazard.
Radiation Hazards: Contact Radiation Safety through EHS at (410)706-7055 for proper equipment clearance.
Biosafety cabinets (BSC’s): Before a Biosafety Cabinet is relocated, disposed of, or moved in any way, it must
be decontaminated by an appropriate vendor (many labs use B&V Testing). After decontamination, the vendor will
place a sticker on the cabinet, indicating that the cabinet has been decontaminated. Once relocated, the vendor must
certify the cabinet in its new location before it can be used again.
Labeling: After equipment is decontaminated, remove or deface any hazard stickers.
EQUIPMENT REMOVAL/CLEARANCE FORM
University of Maryland Baltimore
Complete this form entirely after the equipment has been fully cleaned and decontaminated by lab personnel. If you
have any questions, contact EHS at (410)706-7055.
N
ame of responsible individual: ______________________________________________
Contact person: __________________________________________________________
Email or phone (at least one required):________________________________________
Building and Room Number (s): ______________________________________________
Equipment to be cleared:
Equip. make: __________________ Equip. Model:_____________________
Serial Number: ________________ UMB Tag#:_______________________
Reason for clearance:
□ Moving or removing equipment
□ Disposal of equipment
□ Repair of equipment
□ Upgrading/adding equipment (installing utilities,
adding canopies, etc)
Risk of Contamination:
□ I __________________(enter name) confirm that this piece of equipment did not come into contact with
hazardous or infectious substances
□ The area may have been exposed to potentially hazardous substances and has been cleared.
o Radiation- MUST BE CLEARED BY EHS PERSONNEL, NOT LAB PERSONNEL. Contact EHS at 6-7055
o Biohazards, potentially
infectious agents
Indicate biosafety level of work performed/BSL level:__________________
o Harmful aqueous solutions, buffers, acids, alkalis
o Toxic chemicals
o Recombinant DNA
D
econtamination Statement:
I, _____________________________ (print name) hereby certify that all known biological, chemical and/or radiological
hazards have been eliminated from the affected laboratory equipment listed on this form. I further certify that all listed
work areas have been properly decontaminated and cleaned and are ready for removal/repair/disposal.
Signature of Responsible Individual: ________________________________ Date: _________________
Telephone No. of Responsible Individual: ____________________________
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EQUIPMENT CLEARANCE FORM - Public University of Maryland (University of Maryland, Baltimore)

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Completed 29 August 2020

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