Name: (person completing Form) Contact Details: Date: College: School: Personnel Affected: Academic / Supervisor Responsible: Contact Details: You are confirming chemicals are not on the prescribed list. PROCEDURE TITLE: (CAS No. MUST be completed) CAS Quantity Quantity Workplace List Hazardous Chemicals Used Conc. Hazards No. Used Handled Exp. Limits ALWAYS CHECK BEFORE STARTING ANY EXPERIMENT A less hazardous The substance is a known YES NO YES NO substance can be used carcinogen The substance is a known The substance is a known YES NO YES NO mutagen teratogen The procedure can The procedure can create YES NO YES NO enhance hazards harmful bi-products The procedure can cause an The procedure can cause a YES NO YES NO exothermic reaction build up of pressure If work can be carried out If Fumehood must be used is YES NO YES NO open bench Fire Trace needed
Name: (person completing Form) Contact Details: Date: College: School: Personnel Affected: Academic / Supervisor Responsible: Contact Details: You are confirming chemicals are not on the prescribed list. PROCEDURE TITLE: (CAS No. MUST be completed) List Hazardous Chemicals Used CAS No. Quantity Used Quantity Handled Conc. Workplace Exp. Limits Hazards ALWAYS CHECK BEFORE STARTING ANY EXPERIMENT A less hazardous substance can be used YES NO The substance is a known carcinogen YES NO The substance is a known mutagen YES NO The substance is a known teratogen YES NO The procedure can enhance hazards YES NO The procedure can create harmful bi-products YES NO The procedure can cause an exothermic reaction YES NO The procedure can cause a build up of pressure YES NO If work can be carried out open bench YES NO If Fumehood must be used is Fire Trace needed YES NO