Laboratory Equipment Decontamination Form
Complete and attach this form to equipment used for hazardous materials.
Equipment Owner
Department:
Date:
Principal Investigator:
Lab Mgr:
Room Number and Building:
Service / Transportation / Disposal Provider
Department / Company performing service:
Equipment Type:
Equipment Serial Number:
Service to be performed:
Potential Contaminants
Chemical:
Biological:
Radioactive:
Decontamination Procedure Performed:
Radioactive Materials: If radioactive materials were used or stored in this equipment, contact
OEH&S at 577-1200 to make arrangements for testing and verification of decontamination. Attach
documentation to this form verifying that the equipment is free of contamination.
Equipment Owner: I certify that the above laboratory equipment has been thoroughly cleaned and
decontaminated of all chemical, biological, and radioactive contaminants.
Name
Date
Service / Transportation / Disposal Provider: I certify that the above equipment appears to have
been recently cleaned and all potential contaminants have been removed.
Name
Date
OEH&S 1/02