Laboratory Sign Update Form

A lab sign is the first thing first responders look for when they respond to an incident or fire in your lab. Therefore, it is important to update your lab sign information as contacts or hazards change for your space. Complete the following form to update your lab sign and emergency plan sign. EH&S will update your information and deliver your new signs. If you have questions or need help completing this form, please call our office at 662-325-0026 or email us at labsafety@ehs.msstate.edu.

Contact Information

PI Name*

Department*

Department Main Phone Number*

Building*

Room Number*

PI Email Address*

This will not appear on your lab sign. This simply lets us reach out to you if we have questions about the information you have provided on this form.

First PI Phone Number*

Please provide a cell phone number or an additional number other than your office number.

Phone

Second PI Phone Number*

Phone

Is this a shared lab space?*

If there is more than one PI, please select Yes to add the additional information.

Select

Other PI Name*

Other PI Phone Number*

Phone

Other PI Email Address*

This will not appear on your lab sign. This simply lets us reach out to the PI if we have questions about the information you have provided on this form.

Secondary Contact*

First Secondary Phone Number*

Phone

Second Secondary Phone Number*

Phone

Hazard Information

Is your lab considered a biosafety lab?

Yes

Biosafety Level *

BSL-1

BSL-2

IBC Protocol #*

List the agents present in your lab.*

More Than 1 Entry Door into Lab Space (from hall)?

Doors to side labs or adjacent labs do not need to be counted, only main entrances from hallways.

How Many Entry Doors Into Lab?

Emergency Plan Information

The following emergency equipment is located in this room:

Safety Shower

Eyewash (Plumbed)

Eye Wash Bottle Station

Fire Extinguisher

Fire Blanket

First Aid Kit

Chemical Spill Kit

Biological Spill Kit

Phone

Other

The following emergency equipment is not located in this room, but can be found at:

Equipment

Location

Quickest and safest way to evacuate:*

(i.e. Left out the door, into the stairwell at the end of the hall to the right, down the stairs to the first floor, and out the exit.)

After evacuation, all lab staff should meet at this location:*

(i.e. parking lot on the north side of the building)

Additional Lab Information

Do you want to list addtional contacts or share additional lab information?

If so, please list your additional contacts or lab information here.

Send me a copy of my responses

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