Appendix B
U of M Decommissioning/Decontamination Form for Laboratory Areas or Rooms
Used to store or manipulate Chemical, Biological or Radioactive Materials
Required to prepare a room for renovation, Principal Investigator moving or close-out.
1.
2.
3.
4.
5.
This Form must be completed prior to commencing service, maintenance, renovation or disposal.
EHSO signature is optional.
Up to 2 weeks may be required for EHSO signature in Section D.
If ASBESTOS or MOULD is present or suspected, refer to the Asbestos or Mould Management Program (474-6633)
Fax completed form to Physical Plant at 474-7547 Fort Garry or 789-3933 Bannatyne
Section A:
Requestor
Section B:
Requestor Name (Please Print):
Department:
Tel:
Location - Room
 Whole room
or
Building
 Specific area in room – describe:
Responsible user Name:
Date requested:
Reason for request:
Date Required:
Physical Plant Coordinator OR Contractor Contact:
Is this part of a project or renovation?
Y
N
Name:
Tel:
Call EHSO (474-6633) for consultation. A site visit may identify
specific hazards that require special attention.
Date contacted EHSO:
Section C:
Declaration To Be Completed by Supervisor/Senior Lab Staff
Name: ________________________________________ Tel: ________________
Site history - How long have you been in this space? ______________ years
If less than four years, get information on the history of room use from someone else in the department.
 when
completed
ACTIONS Taken:
C1
Inventory - review your inventory in the U of M chemical inventory database and ensure that:
C1.1
all material is located,
C1.2
all disposed chemicals removed from inventory,
C1.3
potential unstable chemicals identified to hazardous waste program for direct pick-up (e.g. ether, tetrahydrofuran,
picric acid).
all chemicals and chemical waste must be removed from the room – ((Fill in Haz. Waste Removal Form on web:
http://www.umanitoba.ca/admin/human_resources/ehso/emanagement/haz_waste_forms.html).
C1.4
C2.1
Is your chemical inventory list current? Y
N
Have any of the surfaces or remaining equipment been used with potential explosives, mercury, azides, and highly
toxic materials?
Y
N
C2.2
Was the Fume hood used with perchloric acid or hydrofluoric acid?
C2.3
Have all potential explosive hazards been removed or identified?
C1.5
C2
C3
Has this space been used for biological material?
C3.1
C3.2
C4
Y
Y
N
Y
N
N
IF YES, Is the inventory info in your Biosafety Permit current? Y
C3.1.1
Has permit information changes been notified to EHSO?
N
Y
N
All biological waste must be decontaminated (by autoclaving or chemically as appropriate) and disposed as per U of
M Biological Waste Disposal Chart.
Has this been done?
Y
N
Has Radioactive material been used here?
Y
N
If YES, Have you completed and submitted to EHSO a Radioisotope Permit Decommissioning Form?
Door signs and Radioisotope Permits may only be removed by Radiation Safety staff.
C5
C6
Y
N
All unused supplies and apparatus removed from drawers and cupboards and shelves? Y N
All empty laboratory glassware and containers removed? Glassware and brittle plastic disposed in plastic bag lined
cardboard boxes or commercial ‘Broken Glass” boxes.
 when
completed
Actions Taken:
C7
All areas inspected or needles, razor blades, scalpel blades and broken glass and placed in a sharps
container?
Y
N
C8
All containers and apparatus removed from in and under fume hoods and sinks?
C9
All hazard labels (rad, chem, bio) removed/defaced when the hazards is no longer present?
C10
All general garbage removed?
C11
All unwanted lab equipment and apparatus disposed/removed?
C12
EQUIPMENT DISPOSAL (green) sticker applied to all equipment and cabinets going for final disposal? (Sticker can
be obtained from EHSO)
All freezers, fridges, cold rooms, searched for errant vials, samples or glass/mercury thermometers)?
C13
Remove all visible residues, standing liquids, loose particulate material, and quantifiable radiological hazards on
floors, bench tops, shelves, cabinets, refrigerators, surfaces of local exhaust enclosures, inside drawers, and other
potentially contaminated surfaces.
At a minimum, wipe all horizontal surfaces and equipment exterior surfaces with mild detergents such as soap and
water.
If this is a room decommissioning is it possible hazardous materials may be present in the building systems?
 Not applicable  fume hood ducts  drains  other – specify:
C14
C15
C16
Do you have any specific recommendations for PPE or disposal? If yes, please list:
C17
DECLARATION OF COMPLIANCE:
Signature confirms information is Section C is accurate:
______________________
_______________________
Signature of Responsible User
Print name and phone numbers
SECTION D: (to be completed by EHSO only)
EHSO MINIMALLY RECOMMENDED PPE and WORK PRACTICES:
HAZARDS IDENTIFIED:
NOTE:
Physical Plant or Contractor Minimum PPE: Coveralls, Eye and Face Protection and other workplace protection as required by PP or
supervisor.
Lab coat, apron or coveralls (disposable □ or washable □) must be worn if there is any possibility of contamination of the workers body.
When there is any possibility of contamination of the hands, wear re-useable chemically resistant gloves (wash and dry after use) □ or
disposable gloves (required if radioactive contamination is a possibility) □.
Use thicker gloves when physical hazard is also present □.
Eye protection:
(Safety glasses □, Chemical splash goggles □ or face shield □) required if procedure has any chance or producing projectiles,
dust, aerosols or splashes.
Body:
Gloves:
Respiratory protection: required if procedure has any risk of producing: dusts □, hazardous vapors □ or aerosols □.
Respiratory protection is required whenever the worker may be exposed to vented air from fume hoods or other
local ventilation. For exposure to hazardous particulates, dusts, aerosols, the minimum is N-95. For exposure to
hazardous volatile chemicals, a multi-contaminant respirator for organic vapors is required. Respirator training
and fit testing are mandatory.
Hygiene: Wash hands □, clean and disinfect tools □ at the end of the job and whenever chemical, biological or radioactive contamination is a
possibility.
If no sink is readily available□’, take along hand wipes to use until you can wash your hands in a sink.
Disinfectant wipes are
recommended if biological contamination on tools is a possibility □.
Waste containers for any wastes generated - All wastes generated shall be disposed in accordance with Controlled Product Standard, Part B.
specifically: http://www.umanitoba.ca/admin/human_resources/ehso/media/CPSPartB.pdf
Footwear: Feet should be completely covered and provide necessary grip for working conditions.
Specifically:
Bio/Chem Decommissioning : (initials, phone # & date):
Rad decommissioning verified: (RSO initials, phone # & date):