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Emmergency Door Placard Form

This form provides emergency responders with important safety information about hazards in each room of a building. It requires contact information and details any physical, biological, chemical, or process hazards present. Respondents identify hazards like radioactive materials, compressed gases, biological agents, flammable chemicals, and more. The completed forms help emergency personnel respond appropriately and safely in the event of an incident.

Uploaded by

Aadityaa Pawar
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© © All Rights Reserved
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43 views1 page

Emmergency Door Placard Form

This form provides emergency responders with important safety information about hazards in each room of a building. It requires contact information and details any physical, biological, chemical, or process hazards present. Respondents identify hazards like radioactive materials, compressed gases, biological agents, flammable chemicals, and more. The completed forms help emergency personnel respond appropriately and safely in the event of an incident.

Uploaded by

Aadityaa Pawar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Emergency Door Placard Form

Your door placard can provide valuable safety information to emergency responders (SB County Fire, paramedics and
EH&S) about the hazards in the room. Please provide the following information (Please use one form per separate room):
Contact(s): Print Name(s) Campus Phone After Hours Phone1 Position
1.
2.
3.
Building
4. Name
5. Room Number

A. Physical Hazards - check all that apply for each room- if NONE check here
Radioactive Material Lasers (Class III or IV) Compressed gas
X-ray equipment High Voltage Cryogenic Fluid
Magnetic fields (NMR) High Pressure reactor
UV light Other/Physical hazards that Fire Dept. should be informed about:

B.Biological Materials - check/describe all that apply for each room- if NONE check here
Disease – causing agents: Infectious particles:
(the category for Salmonella, Streptococcus, etc.)
(the category for viral vectors that are replication deficient, but infectious)
Human blood products and/or cells:
(the category for human plasma, cerebrospinal fluid, HeLa cells, HEK293 cells, etc.) Other/biological materials that Fire Dept.
Toxins should be informed about:
C.Potentially hazardous unattended processes- check all that apply for each room- if NONE check here
Solvent stills with drying agents Water-cooled equipment
Other hazards that Fire Dept. should be informed
High-Pressure equipment
about:
D.Chemical Hazards - check all that apply for each room- if NONE check here
Laboratory-sized chemical containers Corrosives (acids/bases) (<5gal.) OR (> 5 gal.)
Bulk-sized chemicals (containers > 5 gallons/19.9 liters) *Oxidizers (e.g. O2, nitric/perchloric acid):
*Toxic gas: size
* Water-reactives (> 0.5 lb): Type
Type(s)
Flammable gas: Type
* Pyrophorics (spontaneous combustible):
Type
Flammable liquids (Total volume of solvents): * Organic peroxides (> 0.5 lb): Type
< 5 gallons (20liters) Explosives:
Type
5 to 10 gallons (20-37liters) Other hazards that Fire Dept. should be informed about:
> 10 gallons (37 liters)

*Common Examples of Lab Chemical Hazards


Oxidizers: Water Reactives: aluminum alkyls, calcium, calcium
Gases: oxygen, ozone, oxides of nitrogen, fluorine, chlorine carbide, diethyl zinc, lithium hydride, lithium aluminum
Liquids: nitric acid, perchloric acid, hydrogen peroxide, bromine hydride, potassium, sodium, sodium peroxide
Solids: chlorates, chromates, nitrates, perchlorates, peroxides

Toxic Gases: arsine, chlorine, cyanogen, fluorine, Pyrophorics:


hydrogen cyanide, hydrogen fluoride, hydrogen Gases: diborane, phosphine, silane
selenide, hydrogen sulfide, nitric oxide, phosgene, Liquids: diethyl aluminum chloride, diethyl zinc, trimethyl aluminum
phosphine Solids: lithium, white or yellow phosphorus, potassium, sodium

Organic Peroxides: Contain “peroxy” or “peroxide”


Form Completed By:
in the name of the material
Phone and/or E-mail:
Return form(s) to: Chandra Feeser at Environmental Health and Safety.
Call x-3264 or e-mail caf@ucsb.edu with any questions. Your assistance with this is greatly appreciated.
1 The State of California Information Practices Act of 1977 requires you to be informed that
furnishing your home (or cell) phone number is voluntary, and that there is no penalty for withholding it.

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