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

General Lab Information
Date Form Completed
Campus / Choose ItemMain CampusOxford CampusGrady CampusBriarcliff CampusEmory Univeristy HospitalEmory University Hospital MidtownYerkes (Main Station)Yerkes (Field Station)Wesley WoodsOrthopaedic & Spine CenterVA Medical Center / Building
Department / Floor
Room Number / Marginals/Benches(if applicable) (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.
Contact #1 / Name / Phone Number
Contact #2 / Name / Phone Number
Contact #3 / Name / Phone Number
Equipment Used in the Lab
Check all equipment that is used in your laboratory below.
Lasers / Quantity: / Class: 3B 4 Other (describe):
High Voltage Equipment
ELF/EMF
High Radiation Producing Equipment
Microwave Radiation Producing Equipment
X-Ray Equipment / 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 Level (ACL):specify → / ACL-1
ACL-2 / ACL-3 / ACL-4
Plant Biosafety Level (BSL-x-P):specify → / BSL-1-P / BSL-2-P / BSL-3-P
USDA/APHIS Regulated Material: / These materials require annual submission of theUSDA 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
Combustible Liquid / Phenol, nitrobenzene, ethylene glycol
Corrosives / Hydrochloric acid, sodium hydroxide, sulfuric acid, phenol
Cryogenic Gas / Liquid nitrogen
Emits Flammable Gas / Lithium, sodium, lithium aluminum hydride
Environmental Toxicity / Dichlorodiphenyltrichloroethane, polychlorinated biphenyls
Explosives / Nitroglycerine, wetted lead azide
Flammable Liquid / Ethanol, methanol, acetone, diethyl ether
Flammable Gas / Methane, hydrogen, butane, ethylene
Flammable Solid / Cellulose nitrate, lithium amide, potassium sulfide
Heavy Metals / Mercury, lead, arsenic
Highly Toxic / Botulinum toxin, diphtheria toxin, nitric oxide
Human Carcinogens / Benzene, asbestos, formaldehyde, vinyl chloride
Irritant/Sensitizer / Latex, weak acids
Mutagenicity / Ethidium bromide, sodium azide, benzene
Non-Flammable Gas / Carbon dioxide, nitrogen, helium
Organic Peroxide / Diethyl ether peroxide, methyl ethyl ketone peroxide
Oxidizer / Hydrogen peroxide, bromine, ammonium perchlorate
Pyrophoric / Tert-butyl lithium, lithium, sodium, Grignard reagents
Reproductive Hazard / Lead, acetonitrile, benzene, xylene, toluene
Self-Reactive / Acetylene, sodium azide
Shock Hazard / Picric acid, nitroglycerin, acetylene, urea nitrate
Target Organ Toxicity / Carbon tetrachloride, benzene
Water Reactive / 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
Nitrile / Latex
Cut-Resistant / Butyl
Thermal
Other:
Mucous Membrane Protection: specify → / Face Shield
ANSI Approved Googles / Surgical Mask
Other:
ANSI Approved Glasses with Side Shields
Protective Clothing: specify → / Button Front Lab Coat
Tie Back Lab Coat
Protective Coveralls / Hair Cover
Booties
Scrubs
Other:
Respiratory Protection: specify → / N95
PAPR / Half Face / Full Face
Other:
Hearing Protection: specify → / Ear Plugs / Ear Muffs / Other:
PPE Required While Working in the Lab – Mark all that apply below.
Gloves: specify → / Double-Gloves
Nitrile / Latex
Cut-Resistant / Butyl
Thermal
Other:
Mucous Membrane Protection: specify → / Face Shield
ANSI Approved Googles / Surgical Mask
Other:
ANSI Approved Glasses with Side Shields
Protective Clothing: specify → / Button Front Lab Coat
Tie Back Lab Coat
Protective Coveralls / Hair Cover
Booties
Scrubs
Other:
Respiratory Protection: specify → / N95
PAPR / Half Face / Full Face
Other:
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

Lab Signage Requirements Form_8.dot Revision Date: 26-Feb-14page 1 of 3