Emergency Door Placard Form

Your door placard can provide valuable safety information to emergency responders (Fire, paramedics and EHS) about the hazards in your lab. Please provide the following information:

• Complete the emergency contact information. (First contact is required.)
• Check off the boxes below which are relevant to the hazards of this lab room.

Call Environmental Health and Safety at ext. 28816 or email with any questions to ehs@nova.edu.

Thanks for your help.

Note: All fields marked with a * below are required. All other fields are optional.

User Information

Name

Email

Phone

Contact Information

First Contact

Name

Position

Campus Phone

Mobile Phone

Second Contact

Name

Position

Campus Phone

Mobile Phone

Third Contact

Name

Position

Campus Phone

Mobile Phone

Hazard Information

Building

Room Number

Other Physical Hazards

Volume of Solvents in Flammable Liquids <5 gallons 5-10 gallons >10 gallons

Other Chemical Hazards

Other Biological Hazards

Other Continuously Operating, Unattended Processes