Carcinogen

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					Hazardous Chemical

                            University of Texas at Dallas
                   _____________________________________________
             Hazardous Chemical (Non-Carcinogenic) Safety Plan
Instructions:
All pertinent sections must be completed. Please retain the format as near as possible and
answer questions appropriately placing answers in the space provided. When you have
completed the form, print a copy, then sign and date the signature page. Return a signed paper
copy of the form to Sridhar (Sri) Hanumanthaiah, Environmental Health and Safety, intercampus
mail stop WT 14.

Project Title

Principal Investigator                 Phone

Funding agency or fund source

Department               Room

Date of activity         From                  To

Project Summary

Hazardous Substance
                Maximum quantity on hand

Will the agent be diluted before use?    Yes            No
                              If yes, what concentration?

Principal Hazard

What aerosol hazards will be encountered?


Laboratory where the hazardous substance will be used

Is laboratory posted with an appropriate warning sign?        Yes         No

Highly toxic material should be stored in a locked, posted storage cabinet.

    Indicate specifically where the material will be stored.

Control Procedures

Indicate containment equipment to be used (i.e. fume hood)
Indicate personal protective equipment to be used

Is medical surveillance required?    YES           NO

Describe briefly how contaminated wastes will be handled and disposed of


List personnel working on the project                         Experience


What monitoring procedures are necessary for personnel?


What monitoring procedures are necessary for area contamination?


Emergency Procedures

Emergency contact person
                Office Phone        Home Phone
Indicate emergency procedures in the event of personnel exposure (inhalation, ingestion,
inoculation, etc.)

Indicate emergency procedures in the event of a spill or release not involving personnel
exposure

Animal Use

Are laboratory animals in this research project?        Yes     No

If yes, please provide the following information:
      Animal Project Number
      What is the animal species used in the project?
      Is the chemical injected?                  Yes           No
      Is it inhaled as an aerosol or gas?        Yes           No
      Is it applied to the skin?                 Yes           No
      Is it given orally?                        Yes           No
       If yes is it given in water         gavage      food

Is the hazardous chemical or other hazardous metabolites shed/excreted by the animal?
           Yes No
               If yes,
               What metabolites are produced?
               For how long are hazardous chemicals shed/excreted?
What disposal requirements are there for the animal carcasses?

What disposal requirements are there for the bedding?

_______________________________________________________________________
Part 5. Certification

The information contained in this application is accurate and complete. I am familiar
with and agree to abide by UTD Policies and Procedures and local state and federal
regulations pertaining to the proposed project.

In addition, I agree to abide by the following requirements:

a. I will train staff in: good laboratory practices and techniques required to ensure safety
   for this project, in the procedures for dealing with accidents, and in waste
   management procedures.

b. I will comply with all shipping requirements for hazardous chemicals.

c. I will make available to the laboratory staff copies of the approved protocols that
   describe the potential hazards and the precautions to be taken.

d. I will supervise staff, and correct work errors and conditions that could result in
   breaches of UTD policy.

___________________________________                _____________________________
         Principal Investigator                                 Date
5/23/2005