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 Laboratory
Equipment to be: Transferred Disposed N/A
Was radioactive material used with this equipment or in the laboratory? Yes No
If Yes - was a wipe test performed: Yes No N/A
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? Yes No
Surface areas must be cleaned prior to clearance and all chemicals must be removed.
Additional Information: