1762 Clifton Road, Suite 1200
Atlanta, Georgia 30322
(404) 727-5922
FAX: (404) 727-9778
LAB SIGNAGE REQUIREMENTS FORM
Instructions:
 Answer all questions
 Complete this form electronically & save as <LS-Building-Dept-PI-Lab#>, e.g.,
<LS-RRC-Micro&Immuno-Smith-123>
 Submit the electronic documents to labsign@emory.edu
GENERAL LAB INFORMATION
Date Form Completed
Campus
Choose Item
Department
Building
Floor
Marginals/Benches (if applicable)
Room Number
(example: Bench A1, A2)
Lab Name
Principal Investigator (PI)
Is this lab shared by more than one PI?
No
Yes
EMERGENCY CONTACT INFORMATION
Add at least two individuals (with corresponding emergency phone numbers) that may be listed
on the sign as an emergency contact for off-hour emergencies and alarms. Do not provide
laboratory or office phone numbers.
Name
Phone Number
Contact #1
Name
Phone Number
Contact #2
Name
Phone Number
Contact #3
EQUIPMENT USED IN THE LAB
Check all equipment that is used in your laboratory below.
Lasers
Quantity:
Class:
3B
4
High Voltage Equipment
ELF/EMF
High Radiation Producing Equipment
Microwave Radiation Producing Equipment
X-Ray Equipment
Other (describe):
Magnetic Field
NMR
Particle Accelerator
Fluoroscope
UV Lights
MATERIALS USED IN THE LAB
Radioactive Material (Lab is listed on your RAM Permit) - If checked, add details below.
Authorized Investigator on Radioactive Materials (RAM) Permit:
RAM Permit Number:
Biological Material– If checked, add details below and select all applicable fields.
Biosafety Level: specify →
BSL-2
BSL-3
Other:
Arthropod Containment
ACL-1
ACL-3
ACL-4
Level (ACL): specify →
ACL-2
Plant Biosafety Level
BSL-1-P
BSL-2-P
BSL-3-P
(BSL-x-P): specify →
USDA/APHIS Regulated
These materials require annual submission of the USDA
Material:
Registration Form.
Chemicals – If checked, mark all chemicals in your lab below.
Hazard
Examples
Acute Toxicity
Sodium azide, potassium cyanide, EPA P-Listed Chemicals
Aspiration Toxicity
Carbon monoxide, chlorine gas
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LAB SIGNAGE REQUIREMENTS FORM
Combustible Liquid
Corrosives
Cryogenic Gas
Emits Flammable Gas
Environmental Toxicity
Explosives
Flammable Liquid
Flammable Gas
Flammable Solid
Heavy Metals
Highly Toxic
Human Carcinogens
Irritant/Sensitizer
Mutagenicity
Non-Flammable Gas
Organic Peroxide
Oxidizer
Pyrophoric
Reproductive Hazard
Self-Reactive
Shock Hazard
Target Organ Toxicity
Water Reactive
Phenol, nitrobenzene, ethylene glycol
Hydrochloric acid, sodium hydroxide, sulfuric acid, phenol
Liquid nitrogen
Lithium, sodium, lithium aluminum hydride
Dichlorodiphenyltrichloroethane, polychlorinated biphenyls
Nitroglycerine, wetted lead azide
Ethanol, methanol, acetone, diethyl ether
Methane, hydrogen, butane, ethylene
Cellulose nitrate, lithium amide, potassium sulfide
Mercury, lead, arsenic
Botulinum toxin, diphtheria toxin, nitric oxide
Benzene, asbestos, formaldehyde, vinyl chloride
Latex, weak acids
Ethidium bromide, sodium azide, benzene
Carbon dioxide, nitrogen, helium
Diethyl ether peroxide, methyl ethyl ketone peroxide
Hydrogen peroxide, bromine, ammonium perchlorate
Tert-butyl lithium, lithium, sodium, Grignard reagents
Lead, acetonitrile, benzene, xylene, toluene
Acetylene, sodium azide
Picric acid, nitroglycerin, acetylene, urea nitrate
Carbon tetrachloride, benzene
Calcium carbide, sodium hydroxide, lithium hydride
PERSONAL PROTECTIVE EQUIPMENT (PPE)
PPE Required to Enter the Lab – Mark all that apply below.
Gloves: specify →
Double-Gloves
Latex
Butyl
Nitrile
Cut-Resistant
Thermal
Other:
Mucous Membrane
Face Shield
Surgical Mask
Protection: specify →
ANSI Approved Googles
Other:
ANSI Approved Glasses with Side Shields
Protective Clothing:
Button Front Lab Coat
Hair Cover
specify →
Tie Back Lab Coat
Booties
Protective Coveralls
Scrubs
Other:
Respiratory
N95
Half Face
Full Face
Protection: specify →
PAPR
Other:
Hearing Protection:
Ear Plugs
Ear Muffs
Other:
specify →
PPE Required While Working in the Lab – Mark all that apply below.
Gloves: specify →
Double-Gloves
Latex
Butyl
Nitrile
Cut-Resistant
Thermal
Other:
Mucous Membrane
Face Shield
Surgical Mask
Protection: specify →
ANSI Approved Googles
Other:
ANSI Approved Glasses with Side Shields
Protective Clothing:
Button Front Lab Coat
Hair Cover
specify →
Tie Back Lab Coat
Booties
Protective Coveralls
Scrubs
Other:
Respiratory
N95
Half Face
Full Face
Protection: specify →
PAPR
Other:
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Revision Date: 26-Feb-14
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LAB SIGNAGE REQUIREMENTS FORM
Hearing Protection:
specify →
Ear Plugs
Ear Muffs
Other:
ADDITIONAL NOTES FOR SIGNAGE
Select verbiage to be displayed on the signage below.
Authorized Personnel Only
Restricted Access
OSHA REGULATED CHEMICALS
Check all chemicals that are present in the lab.
Chemical Name
CAS Number
1,2-dibromo-3-chloropropane
96-12-8
1,3-Butadiene
106-99-0
2-Acetylaminofluorene
53-96-3
3,3'-Dichlorobenzidine (and its salts)
91-94-1
4-Aminodiphenyl
92-67-1
4-Dimethylaminoazo-benezene
30-11-7
4-Nitrobiphenyl
92-93-3
Acrylonitrile
107-13-1
alpha-Naphthylamine
134-32-7
Benzene
71-43-2
Benzidine
92-87-5
beta-Naphthylamine
91-59-8
beta-Propiolactone
57-57-8
bis-Chloromethyl ether
54-28-81
Cadmium
7440-43-9
Ethylene Oxide
75-21-8
Ethyleneimine
151-56-4
Formaldehyde
50-00-0
Inorganic arsenic
Inorg arsenic
Lead
7439-92-1
methyl chloromethyl ether
107-30-2
Methylene Chloride
75-09-02
N-Nitrosodimethylamine
62-75-9
Vinyl Chloride
75-01-4
Methylenedianiline
1-1-77-9
Please submit the form electronically to labsign@emory.edu
Lab Signage Requirements Form_8.dot
Revision Date: 26-Feb-14
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