Appendix A

U of M Decommissioning/Decontamination Form for Laboratory Equipment

(ONE Form per Item please)

1. This Form must be completed prior to commencing service, maintenance, renovation or disposal.

2. EHSO signature is optional.

3. Up to 2 weeks may be required for EHSO signature in Section D.

4. If ASBESTOS or MOULD is present or suspected, refer to the Asbestos or Mould Management Program (474-6633)

5. Fax completed form to Physical Plant at 474-7547 Fort Garry or 789-3933 Bannatyne

Section A: Requestor: / Section B: Equipment Description:
Reason: ð Disposal ð Servicing ð Maintenance
Name (Please Print):
Department: / Location:
Room Building
Tel: / Type of Equipment:
Responsible user Name: / Make and Model:
Date requested: / Serial Number
Date Required: / U of M Property # OR other ID (specify):
If the equipment has a U of M property #, then the Asset Disposal Form been completed and approved? ð
Is this part of a project or renovation? ð Y ð N
Physical Plant Coordinator OR Contractor Contact:
Name Tel:
Section C: To be completed by Senior Lab Staff
C1. How many years of history do you have on this item? ______
C2. For the item above indicate the related hazardous materials usage:
Hazardous Material / If never used / If applicable, record related information here / C3. Decontamination
Information
Radioactive material / ð / Specify isotope(s) and when: / What was done (check all that apply):
ð All needles, razor blades, broken glass removed and disposed according U of M Protocol
ð Minimum requirement is that all equipment from labs is surface wiped with water & mild detergent to remove surface dust, debris.
ð interior only ð exterior only
ð both interior and exterior
ð monitored for radioactive contamination
(attach results)
Date______
ð 1/5 bleach with 30 min soaking
ð 70% ethanol with 30 min soaking
ð other - specify type and concentration:
Date Completed:
Done by:
Name (Please Print) Tel:
Biological material or blood and body fluids / ð / Specify type and when:
Has BSC been surface disinfected-inside and out- if it is to remain in the renovation area? ð
Hazardous chemicals or gas/vapour in equipment / ð / Consider: Highly toxic material, perchloric acid, hydrofluoric acid, corrosives, mercury. Specify type and when:
Collect in sealed containers and label as hazardous waste.
Oil, vacuum pump oil, PCB’s in equipment / ð / Drain vacuum pumps of oil into containers and label and dispose with hazardous waste program (PCBs?)
Lead or other leachable metals present, including in any internal components of equipment / ð / Removed ð or
List on green Equipment Disposal sticker ð
Other hazards or pertinent information / ð
C4. All hazard labels removed once equipment is decontaminated? ðY ðN
C5. If this is an equipment decontamination/disposal have you checked with the manufacturer regarding any specific instructions or hazardous internal components? If yes, please append information (check here if information is appended) ð Y ð N
C6. Do you have any specific recommendations for PPE or disposal? If yes, please list on back ð Y ð N
DECLARATION OF COMPLIANCE: Signature confirms information is Section C is accurate.
Signature of Responsible User Print Name and Phone # of Responsible User
Section D1: / Section D2: To be completed by EHSO upon request of physical plant
Any special instructions (itemize and initial) use extra page
as required: Check here if information is appended ð
For Personnel carrying out disposal minimum PPE are:
ð Coveralls
ð Eye and Face Protection
Additional workplace protection required by units:
ð Gloves, specify type ______
ð Respiratory Protection- specify ______
ð Other – describe______/ Bio/Chem Decommissioning:
(initials, phone & date) / Rad Decommissioning verified:
(RSO initials, phone & date)