Laboratory Cleanout Request Form

To request removal or relocation of laboratory equipment or furniture, please complete this form. Risk Management will contact you to arrange final approval.

For more information on this program, see the Laboratory Clean-out Guidelines.

Note: If you will be using 2Fix to request equipment relocation or removal, you must also submit a 2Fix request. This form is for safety clearance only.

Contact Name*

Full Legal Name

Contact E-mail*

Primary E-mail

I am requesting a*

Item Disposal/Recycle

Item Relocation

Chemical Purge

Requesting Department*

Department Name

Principle Investigator*

Person who oversees and/or owns items for removal.

Location of Items*

Building and Room Number(s)

Items to be Removed*

Please list or describe the type of items requested to be removed or relocated (e.g. autoclave, centrifuge, flammable chemicals, biosafety cabinet, etc)

Equipment Contains

Oil (e.g. pumps; transformers; capacitors)Refrigerant gas or antifreeze

High risk chemicals (e.g. perchlorates; peroxide-formers; strong acids/bases)

Mercury (mercury compounds or components; ie switches; lamps; thermometers etc)

Asbestos (asbestos tape or wool; transite; gloves)

Biological agents (e.g. cell cultures; human/animal tissue; live animals)

Radioactive materials or radiation producing equipment

Lead shielding

Equipment has never contained any of the items listed above

Check all that apply

Describe Chemicals (if applicable)

e.g., Radioisotopes, biological agents, or high risk chemicals

Describe Cleaning/Decon Measurers

Include cleaning agent/method used, who performed the cleaning, and when

Lab Clean Out Form | American University Washington DC

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Laboratory Cleanout Request Form