Environmental Health & Safety Supplemental Approval Form

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 #:
Where 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
Where will hazardous material be prepared (lab, room, fume hood, BSC, etc.)?
Lab door signage will read:
Required PPE for preparation:
Clean-up procedures:
Waste disposal procedures:
b) Exposing animals to hazardous material
Where in animal facility will work be conducted?
Animal room signage will read:
Required PPE for animal use personnel:
Clean-up procedures:
Waste disposal procedures:
c) After exposing animals to hazardous material
Time frame (how long will animals be kept following exposure):
Animal room signage will read:
Required PPE for animal use personnel:
Cage change frequency:
Bedding disposal procedure:
Carcass disposal procedure:
Waste disposal procedure:
d) Termination of hazardous experiments in animals
Time frame (how long will hazard be present):
Animal room signage will read:
Required PPE for animal use personnel:
Cage change frequency:
Bedding disposal procedure:
Carcass disposal procedure:
Waste disposal procedure:
e) Action to take in event of accidental exposure to hazardous material
Needle stick or other sharp:
Skin or mucous membrane exposure:
Ingestion exposure:
Inhalation exposure:
Where to seek medical attention:
Accident reporting procedure:
f) Drugs, antidotes, or immunizations available to hazardous material
Drugs and dosage:
Antidotes and dosage:
Immunization:
For IACUC Use Only: Date and name of person reviewing including comments (boxes will expand as text is entered)
Environmental Health & Safety:
Biomedical:
Controlled Substances:
Biosafety:
Risk Management:
Laser Safety: