Purpose for Request *Select one of the followingNew LaboratoryLaboratory ModificationRelocation of existing LaboratoryRepurposing of existing LaboratoryDecommissioningCloseoutModification Details (for Modification Requests)Type of laboratory *Select one of the followingTeachingResearchClinicalShared SpaceFieldLab Location (Building/Rm): *Principal Investigator (PI): Last Name: *First name: *Phone Number: *E-mail: *Department *Department Chair: *Comittee Approval (Select all that apply using dropdown menu)Committee(s)Select oneInstitutional Animal Care and Use Committee (IACUC)Institutional Review Board (IRB)Institutional Biosafety Committee (IBCRadiation Safety Committee (RSC)Date of ApprovalHazard Assessment(s) Completed (Select all that apply) *Biological Hazard ID and Risk AssessmentChemical Hazard ID and Risk AssessmentEnvironmental Impact AssessmentErgonomic AssessmentLaser Safety AssessmentRadiation Safety AssessmentProcess hazard Analysis/HAZOPPPE AsssessmentMedical Safety AssessmentFire and Life Safety AssessmentLaboratory Equipment AssessmentMost Recent Date of Assessment *Hazard categories (Check all that apply): *AnimalsBiological Material ( Toxins, Microorganisms, Pathogens, agents, etc)Hazardous ChemicalsGeneral Laboratory Chemicals (non-hazardousCryogensHuman material (blood, tissues, bodily fluids, cell culture, etc)High-pressure systemsLaserRadioactive materialsRadiation-Producing equipmentNon-ionizing radiationRecombinant DNA/Synthetic Nucleic AcidsCompressed gasesSpecialized equipment (List all that apply)example: Biosafety cabinet, fume hood, x-ray equipment, laser, cyrogens, fire cabinet, corrosive cabinet, NMR, etc)SOP's developed and available *Select one of the followingYesNoSOP approval dateLaboratory Setup Checklist Completed *Select one of the followingyesnoDate of Completion for Lab Setup ChecklistLaboratory Closeout/Decommision Checklist CompletedYesNoDate of completion for lab closeout/decommission checklist Submit Form
