Download High Hazard Chemical Registration Form

Registration #:
Expiration Date:
Environmental Health and Safety
High Hazard Chemical Registration Form
High Hazard
Chemical Name:
Chemical
Synonyms
(or Drug name):
CAS#
IACUC* Protocol
# (if applicable):
IACUC Protocol
Expiration Date:
Personnel Information
Principal
Investigator:
Building/Room:
Alternate Contact:
Department:
Cell
Phone**:
Cell
Phone**:
Name of all personnel handling registered chemical:
Project Title
Please provide the Safety Data Sheet (SDS) for this chemical with the registration form. Safety Data
Sheets are available from the supplier or maker of this chemical and must be the most current version. As
per the Tufts University Chemical Hygiene Plan, work with hazardous substances cannot be carried out
without SDS present, read and understood by all personnel involved.
* Institutional Animal Care and Use Committee (IACUC)
** Cell phone numbers for after- hours emergency contact.
*** Personal Protective Equipment (PPE). Protective clothing, gloves, goggles, respirators, or other garment designed
to protect the wearer's body from injury by blunt impacts, electrical hazards, heat, chemicals, and infection, for
job-related occupational safety and health purposes.
200 HAR RISON A VENU E, BOSTON, MA 02111 | TEL 617.636.3615 | FAX 617.636. 2419 | publicsafety.tufts.edu/ehs
TUFTS UNIVERSITY/ TUFTS CUMMINGS VETERINARY / TUFTS MEDICAL CENTER
TUFTS EHS
HIGH HAZARD CHEMICAL REGISTRATION FORM
|D e c e m b e r 2 0 1 6
Registration #:
Expiration Date:
Specific Questions
1. a) Location of use and storage (Laboratory Bldg/Rm & Animal Care Facility Bldg/Rm):
b) Quantities being used:
c) Quantities stored:
2. Experimental procedures: briefly describe the procedures that will involve the use of this high hazard
chemical. For animal studies, what is the route of administration, dosing and frequency of dosing?
For laboratory chemicals, how is the chemical used in the lab?
3. Describe procedures to control/ minimize individual exposure to the chemical during handling:
4. Outline decontamination and disposal procedures for the hazardous chemical. Include both the disposal
of the agent itself as well as the disposal of any items that may be contaminated with the agent
(e.g., gloves, paper towels, eppendorf tubes, other containers, pipette tips, etc.):
5. Outline emergency procedures in the event of an unplanned exposure incident
(refer to Tufts University Emergency Response Guide, first aid/hazardous spill section).
6. Is personal protective equipment (PPE) required for handling registered chemical in laboratory
(Gloves, respirator, goggles, etc.)?
If so, please specify what PPE*** and when it is used.
200 HAR RISON A VENU E, BOSTON, MA 02111 | TEL 617.636.3615 | FAX 617.636. 2419 | publicsafety.tufts.edu/ehs
TUFTS UNIVERSITY/ TUFTS CUMMINGS VETERINARY / TUFTS MEDICAL CENTER
TUFTS EHS
HIGH HAZARD CHEMICAL REGISTRATION FORM
|D e c e m b e r 2 0 1 6
Registration #:
Expiration Date:
Specific Questions
7. Is personal protective equipment required for handling registered chemical in the Animal Care Facility
(Gloves, respirator, goggles, etc.)?
If so, please specify what PPE*** and when it is used.
8. a) Identify any special animal care or handling procedures necessary for handling animals exposed to
this agent. Please be specific.
It is the PI’s responsibility to inform the Animal Facility Manager (6-7265)/staff whenever beginning
research with a hazardous agent in animals.
b) Please detail pharmacokinetics of this agent, including systemic uptake, percent metabolized to a
non-hazardous form, percent excreted in active/hazardous form, etc.
(This is required so that we may make a determination of final disposal of bedding, handling of
cages).
Project Approval
Signature of PI
Date
Signature of Chemical Safety Officer
Date
This form is available on the Tufts EHS Web site at http://publicsafety.tufts.edu
Please contact the Tufts EHS at 617-636-3615, for further information. Upon completion of this form, please insert electronic
signature and email to [email protected]. Upon review and approval, a singed registration form along with an approval
letter will be sent to the PI via email. Approvals are granted for a 3-year period for chemicals used in vivo.
200 HAR RISON A VENU E, BOSTON, MA 02111 | TEL 617.636.3615 | FAX 617.636. 2419 | publicsafety.tufts.edu/ehs