Environmental Health & Safety

Clearance Request Form

Researcher Requesting Clearance
First & Last Name:
Ext:
Alt. Number:
Pricipal Investigator:
Department:
Location of Equipment/Laboratory
Building:
Room:
Equipment: (Type “None” if not Equipment)
Clearance Checklist completed?
Equipment to be:
Was radioactive material used with this equipment or in the laboratory?
If Yes - was a wipe test performed:
Wipe test of the equipment or radioactive work areas must be done and the result submitted to EH&S prior to clearance.
Were all surface areas cleaned with alcohol or 10% bleach solution?
Surface areas must be cleaned prior to clearance and all chemicals must be removed.

Additional Information:

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