University of Texas at Dallas
Hazardous Chemical (Non-Carcinogenic) Safety Plan
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.
Principal Investigator Phone
Funding agency or fund source
Date of activity From To
Maximum quantity on hand
Will the agent be diluted before use? Yes No
If yes, what concentration?
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.
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 contact person
Office Phone Home Phone
Indicate emergency procedures in the event of personnel exposure (inhalation, ingestion,
Indicate emergency procedures in the event of a spill or release not involving personnel
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?
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
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