Department_________________________________________________________________

Name of Responsible User___________________________________________________

Campus Address_______________________________________Phone_________________

Home Address_________________________________________Phone_________________

Chemical Name________________________________________CAS___________________

Number of Individuals Potentially Exposed _________________________________

MSDS Present in the Use Room? YES________________NO*____________

All Necessary Safety Equipment Present and in Good Condition? YES___NO*____

All Personnel to Receive Training Relative to the Prescribed Safety Precautions? YES ____ NO* ____

All Personnel to Receive Orientation to the Appropriate Emergency Response

Actions? YES____ NO* ____

Time Period Over Which Chemical to be Used. From ____________To__________

Quantity Per Time Interval to be Used. ________________Per________________

How Will Any Waste Generated be Stored and Disposed of?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

In the space provided below, and on any necessary additional sheets, describe how the chemical is to be used and indicate specifically what safety precautions will be used.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

* Explain a No Response

NAME______________________________________DATE_____________________________