UNIVERSITY OF COLORADO DENVER
Environmental Health and Safety Department, Office of the Assistant Vice Chancellor for Regulatory Compliance
(303) 724-0345

CLEARANCE FORM FOR DEPARTING PERSONNEL

Please submit this form as your earliest opportunity after you determine that your employment at UC Denver will terminate.

Your Name Employee ID
Dept. Name P.I. or Supervisor's Name
Work Phone # Campus Box #
Date of Departure Building
Room #
 
Please provide a forwarding address so that we may notify you of any Industrial Hygiene issues which may have arisen while you worked at UC Denver.
Street Address City
State Zip
Phone Number
 
Have you worked with and/or handled radioisotopes while at UC Denver, or were you otherwise exposed to radioactivity such that you wore a dosimeter film badge? Yes   No
If yes, please send all remaining films, holders, and TLD ring badges to Health and Safety - Attn. Rad. Safety, Box F484.
 
“If you worked in a laboratory, were you listed as an Emergency Contact? Yes   No
If yes, provide replacement's name, office #, home #
 
Is your entire laboratory staff leaving the UC Denver campuses (moving to a non-UC Denver entity)? Yes   No
 
If your entire lab staff is departing, your laboratory, in most cases, must remove all remaining wastes, supplies, equipment, and furniture. Equipment or lab surfaces that were in contact with chemicals, biological materials or radioactive materials must be properly decontaminated by the researchers according to the Health & Safety Department's Decontamination Procedures for Laboratory Equipment/Lab Surfaces. Please decontaminate your laboratory equipment and surfaces according to these procedures so that your area will be safe for the new occupants, or for demolition, as the case may be. You can find the laboratory decontamination procedures at this link: http://www.uchsc.edu/safety/HazardousWaste/GreenTagging.htm.
 
If you are the only one leaving your lab, make sure you have clearly labeled and transferred all radioactive, chemical, reagent containers to another approved investigator in your lab/department or have properly disposed all of these materials as waste through the Health and Safety Department. Important: Clearly label chemical contents: stock solutions, sample containers and micro-centrifuge tubes. Do not abandon containers labeled with cryptic markings that only you can decipher.
 
By clicking the "Submit" button below, I am certifying that I have not abandoned any research materials (chemicals, biological materials, radioactive isotopes) including waste containers, prepared stock solutions or sample containers in any of the laboratories that I have worked in the past.