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.

Full Legal Name

Primary E-mail

   
   
   
Department Name

Person who oversees and/or owns items for removal.

Building and Room Number(s)

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

   
   
   
   
   
   
   
   
Check all that apply
e.g., Radioisotopes, biological agents, or high risk chemicals

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