APPENDIX 5-B
Cole Science Center
NOTIFICATION OF USE OF PARTICULARLY HAZARDOUS SUBSTANCES
HAZARD CATEGORY:
___ SELECT CARCINOGEN
___ HUMAN REPRODUCTIVE TOXIN
CHEMICAL NAME:
______________________________________
CAS #:
(if known)
______________________________________
USED IN :
___ RESEARCH – List Faculty Name
______________________________ext:_______
___ STUDENT LABORATORIES
Course
Responsible Faculty
_________________________________________
_________________________________________
AREA OF USE:
________________________________________
STORAGE AREA:
________________________________________
USED ONLY IN FUME HOOD:
___YES
___NO
APPROXIMATE QUANTITY USED: PER EXPERIMENT __________________
PER WEEK _________________________
Requirements for the use of Select Carcinogens and Reproductive Toxins are described in those
sections of the Safety Manual. The Safety Committee may request a written protocol or other
additional information upon review of this Notification.
_________________________________
Signature
Date: _______________
Return to Lab Manager