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									     Place X here if renewal                                   This form required by the Chemical Safety
     Place X here if amendment                     Committee for all EXTREME and HIGH hazard projects

                                               APPENDIX 1

                           Oregon State University – Environmental Health & Safety
                         Application/Registration for Use of Chemical Carcinogens

Choose a category of carcinogen use:
        Extreme hazard carcinogen only
        Extreme hazard carcinogen use and High hazard carcinogen use
        High hazard carcinogen use only

1)   Date

2)   Applicant

3)   Dept

4)   Location of work:
     Building                           Room number(s)
     Bldg A                             127, 135
     Bldg B                             234, 345

5)   Names of all personnel participating in the project. Include employee identification number (EIN).
     Place “X” in front of extreme hazard carcinogen handlers.

      Name                                                   EIN
      X First Last                                           930XXXXXX
      First Last                                             930XXXXXX


6)   Chemical Carcinogen/CAS number                                  Annual amt needed      Physical Form

      e.g. chemical/XX-XX-X                                          600 mg                 Solid



7)   Anticipated duration of project:

8)   If for course offering, list course number:

9)   Will experimental animals be used (yes or no)?          If YES:
     ACUP # =
     Attach Chemical Agents use in Animals form - http://oregonstate.edu/ehs/forms/auf.doc

10) Attach a brief statement of purpose and written protocol that includes methods of decontamination or
    disposal of materials used.

11) For Extreme carcinogens
      a. Attach written protocols, as described in section 2 of the chemical carcinogen safety manual,
          that describe the project in detail. Describe which activities occur in what locations.
      b. For amendments, list changes only.
      c. New applicants: provide a copy of the applicant’s C.V.

Document1                                                                                 UPDATED 3/18/2009
(appendix I page 2)


            d. Provide evidence of medical surveillance, including pre-assignment examination, plan for or
               records of periodic examinations, and any special requirements as indicated by the consulting
               physician. Contact EH&S for appropriate form.

12) All use of chemical carcinogens listed in this application will be in conformance with the requirements
    listed in the OSU Chemical Carcinogen Safety Manual. All personnel will read the manual and will be
    adequately trained in the safe use of chemical carcinogens.


      Applicant’s signature                                                    Date


      Department Chairperson                                                   Date


13) Application/registration approved:


      Chemical Safety Committee Chair – Extreme carcinogens only               Date


      Office of Environmental Health & Safety                                  Date




Document1                                                                                      Updated6/30/08

								
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