Environmental Health & Safety Supplemental Approval Form Instructions: Please complete the entire form, attach the Safety Data Sheet (SDS), and submit with the IACUC protocol. A separate form must be completed for each hazardous material. The boxes will expand as text is entered. Animal use personnel associated with the proposed hazardous material use must update their Animal Contact Program exposure and health information with the Holzer Health Center. 1. Description of Hazardous Material Chemical Name: Route(s) of toxicity (e.g. inhalation): Type(s) of toxicity (e.g. irritant): Biohazard Name: Route(s) of infection: Biohazard level: Radioisotope Name: Route of administration: Physical Hazard: Route of administration: Other (describe): Route of administration: Description of material (form upon receipt, solubility, volatility, form as used, vehicle, etc.): If applicable, Manufacturer: Product #: will the material be stored prior to use (room, refrigeration, etc.)? 2. Proposed Use of Hazardous Materials in Animals Animal species to be dosed: Proposed work location: Dose per animal: Route of delivery: Treatment schedule: Time treated animals will be maintained: Number of animals to be treated for each experiment: 3. Fate of Hazardous Material (Where does the compound go after dosing the animal?) Route of excretion: What is excreted: Percent excreted: Where is the hazard? How long is it present? Describe where the hazard exists and how it should be handled: 4. Institutional Approvals for Using Hazardous Materials (Does this work require additional approvals? Please attach approvals if previously acquired.) Institutional Biosafety Committee (IBC) approval date: Radiation Safety Committee approval date: 5. Exposure Risk Management a) Preparing hazardous material will hazardous material be prepared (lab, room, fume hood, BSC, etc.)? Lab door signage will read:
Environmental Health & Safety Supplemental Approval Form Instructions: Please complete the entire form, attach the Safety Data Sheet (SDS), and submit with the IACUC protocol. A separate form must be completed for each hazardous material. The boxes will expand as text is entered. Animal use personnel associated with the proposed hazardous material use must update their Animal Contact Program exposure and health information with the Holzer Health Center. 1. Description of Hazardous Material Chemical Name: Route(s) of toxicity (e.g. inhalation): Type(s) of toxicity (e.g. irritant): Biohazard Name: Route(s) of infection: Biohazard level: Radioisotope Name: Route of administration: Physical Hazard: Route of administration: Other (describe): Route of administration: Description of material (form upon receipt, solubility, volatility, form as used, vehicle, etc.): If applicable, Manufacturer: Product #: will the material be stored prior to use (room, refrigeration, etc.)? 2. Proposed Use of Hazardous Materials in Animals Animal species to be dosed: Proposed work location: Dose per animal: Route of delivery: Treatment schedule: Time treated animals will be maintained: Number of animals to be treated for each experiment: 3. Fate of Hazardous Material (Where does the compound go after dosing the animal?) Route of excretion: What is excreted: Percent excreted: Where is the hazard? How long is it present? Describe where the hazard exists and how it should be handled: 4. Institutional Approvals for Using Hazardous Materials (Does this work require additional approvals? Please attach approvals if previously acquired.) Institutional Biosafety Committee (IBC) approval date: Radiation Safety Committee approval date: 5. Exposure Risk Management a) Preparing hazardous material will hazardous material be prepared (lab, room, fume hood, BSC, etc.)? Lab door signage will read:
EHS-supplemental-approval-form.docx