Biohazard Form

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					                                   University of Colorado Health Sciences Center
                                           Animal Care & Use Program
                                   Hazardous Material Information Questionnaire

Note: Standard Operating Procedures (SOP) will be prepared for use of this hazardous material, based upon this
questionnaire. Please be complete and accurate.
Principal Investigator & Phone Number              Protocol Number



Species to be used                                                    Name of Substance



Amount Per Animal                                                     Dates of Usages (from / to):



Route of Administration                                               Length of Hazardous Period

Route of Excretion

                                                Hazard Class of Substance …. (check box)
Attach a copy of material safety data sheet (MSDS) to the questionnaire if the substance is not found on list of
“hazardous drugs” attached to this section.
___Moderately Toxic Chemical (no special hazards) . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . vitamins, aspirin, etc.
___Highly Toxic Chemical (LD 50 < 50 mg/kg) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sodium cyanide, strychnine
___ Toxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . aflatoxin, pricro toxin, cholera toxin, snake, etc.
___ Experimental or Investigational Drugs . . . . . . . . . . . . . . . . . . . . . . ( hazardous mechanism of action)
___ DEA Controlled Substances . . . . . . . . . . . . . http://www.deadiversion.usdoj.gov/schedules/index.html
___ Hazardous Drugs . . . . http://www.uchsc.edu/safety/Downloads/CommonHazardousDrugs08-06-04.pdf
___ Carcinogen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . antineoplastic drugs, methyl methanesulfonate
___ Mutagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ethidum bromide, penazine methosulfate
___ Teratogen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lead, bromodeoxyuridine
___ Reproductive Toxicity at low doses ( 1 mg/kg/day) . . . . . . . . . . . . . . . . . . . . (handle as hazardous drug)
___ Organ Toxicity at low doses (1 mg/kg/day) . . . . . . . . . . . . . . . . . . . . . . . . . . (handle as hazardous drug)
___Radioactive Materials . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . carbon-14, tritium, I-131
___ Human infectious agents. . . . . . . . . . . . . http://www4.od.nih.gov/oba/rac/guidelines_02/APPENDIX_B.htm
___Animal infectious agents . . . . . . . . . . . . . . . . . . . http://www.aphis.usda.gov/vs/ncie/pdf/agent_toxin_list.pdf
___Select Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . http://www.cdc.gov/od/sap/docs/salist.pdf

Potential for Disease in Humans (include NIH Risk Group category if known)




Potential for Disease in Animals




                                                                         1
Personnel Protective Equipment Required (check all that apply)

___Gloves (latex, nitrile, neoprene, rubber, PVC) ___ Dust Mask ___Shoe Covers ___Scrubs              ___Gowns

____Head Cover     ___ Respirator (HEPA, chemical, other) ___Face Shield ___Eye Protection
___ Other (Specify):



Radioactive Materials     For radioactive materials follow the procedure below:




Containment Procedures For hazardous drugs, experimental drugs, select agents or substances which are:
carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Containment Procedures Guidance:




Bedding Change Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens,
mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Bedding Change Guidance:




                                                        2
Cage Cleaning Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens,
mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Cage Cleaning Guidance:




Waste Handling Procedures For hazardous drugs, experimental drugs, substances which are: carcinogens,
mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Waste Handling Guidance:




Carcass Disposal Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens,
mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Carcass Disposal Guidance:




                                                      3
Personnel Exposure Emergency Procedures For hazardous drugs, experimental drugs, or substances which are:
carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Personnel Emergency Guidance:




Spill Procedures       For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens,
teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Spill Procedure Guidance:




Personnel Exposure Monitoring Procedures           For hazardous drugs, experimental drugs, or substances which
are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:




Additional Personnel Exposure Monitoring Guidance:




                                                         4
Other Protection, Monitoring, or Control Procedures not Included Above For hazardous drugs, experimental
drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses,
follow the procedure below:




Other Contact Personnel (Include telephone numbers)




RETURN COMPLETED FORM TO: IACUC Office                      Questions? Call 303.724.1056




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posted:12/11/2011
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