Laboratory Certification Form
  • Principal Investigator:
    		•
                  Date:
           
  • Dean/Dept. Chair:
    		•
                  Date:
           
  • Department(s):
    		•     
           
  • Laboratory Location:        Room:
    		•
             Building:
           
  • Material(s) or Hazard Group:
    		•     
           
  • Maximum Quantity On Hand:
    		•  < liter or 100 gm    
      1 liter/100 gm to 5 liters/1 kg  
      5 liters/kg to 20 liters/5 kg  
      > 20 liters/5 kg    
           
    • Concentration Used:
    		 Dilute (< 5%)    
      Intermediate (5–25%)  
      Concentrated (> 25%)  
           
  • Check the hazards that apply:
    		•       
    Flammable Corrosive Reactive Acute Toxicity  
    Chronic Toxicity Carcinogenic Teratogenic Biological  
    Radioactive        
           
  • Chemical/Biological/Radioactive Information and Training:
    		•
     
       (a) Is safety information for these materials available?
           Yes
           No
       (b) Has training in the safe use of these materials been provided to all potential users?
           Yes
           No
     
  • What control measures are necessary to use the materials safely?
    		•
     
  • If Engineering Controls are utilized for the following:
    		•
       (a) Fume hood - model type and certification numbers
       (b) Biosafety Cabinet - model type and certification numbers
     
  • Personal Protective Equipment Needs (Example: Nitrile gloves):
    		•
     
  • Emergency Response Equipment Available:
    		•  Safety Shower  
      Eyewash Station  
      Spill kits  
      Fire Extinguishers  
     
  • Environmental Sampling Requirements? If so what types and frequencies required?
    		•
     
  • Is medical monitoring required? If so what employees and for what materials?
    		•
     
  • Where and with what equipment are the material(s) to be stored?
    		•  Room
     
  • If refrigerator(s) or freezer(s) are they fire rated or chemical resistant?
    		•
     
  • Method of disposal:
    		•  Autoclave    
      Incineration    
      Contractor    
      SEC waste stream    
     
  • Identify the person(s) to be working in each laboratory and title:
    		•
     
  • Have all the necessary Material Safety Data Sheets been compiled and made available to staff?
    		•
    • Location easily assessable?
     
  • Worker exposure to hazardous chemicals, biological and radioactive materials required risk assessment before the work begins. Indicate who and how the employee health issues will be assessed:
    •  
  • Identify the department(s) under whose control this work will be done:
    		•
     
  • Unusual or special precautions to be used; define per hazard:
    		•
    • Storage requirement
    		    
    • Shock sensitive
    		    
    • Security issues
    		    
    • Spill containment
    		    
     
    As principal Investigator and/or Laboratory Director, I have primary responsibility for compliance with University Biological, Chemical and Radiation Safety policy and procedure compliance as they apply to laboratory(s) and personnel within my authority. All information provided on the Laboratory Certification form is complete and accurate to the best of my knowledge. I understand that one of the following: Safety and Environmental Compliance, Institutional Biosafety Committee or the Radiation Safety Committee may and will inspect the laboratory(s) at least annually for compliance. Any deficiencies noted during inspections must be corrected within the time frame given or closure of the laboratory will occur.
     
     
     

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    Last date changed: January 29, 2009
    URL: http://www.southalabama.edu/environmental/laboratorycertificationform.html