Department of Environmental Health & Safety
Carcinogen Material Reporting Form
(Type or Print Legibly)
1. ___2-Acetylaminofluorene
2. ___4-Aminodiphenyl
3. ___Benzidine (and its salts)
4. ___3.3’-Dichlorobenzidine (and its salts)
5. ___4-Dimethylaminoazobenzene
6. ___alpha-Napthylamine
7. ___beta-Naphthylamine
8. ___4-Nitrobiphenyl
9. ___4-Nitrosodimethylamine
10. ___beta-Propiolactone
11. ___bis-Chloromethyl Ether
12. ___Methyl Chloromethyl Ether
13. ___Ethyleneimine
14. ___Methylene Chloride
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
___Methylenedianiline (MDA)
___Cadmium
___Asbestos*
___Vinyl Chloride
___Coke Oven Emissions
___1,2,-Dibromo-3-Chloropropane
___Acrylonitrile
___Inorganic Arsenic
___4,4’-Methylenebis (2-Chloroaniline)
___Formaldehyde
___Benzene
___Ethylene Dibromide
___Ethylene Oxide
___1, 3 Butadiene
*Raw forms of Asbestos used in research activities.
If you checked any of the materials listed above, please complete the following information:
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
_______________________________________________________________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
________________________________________________________________________
Note: Please use attached pages for listing additional chemicals.
Contact Name___________________________Ext.______
Department_______________________
Total number of regulated materials__________
Total number of pages submitted to include this cover page.___________
Today’s Date_______________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
_______________________________________________________________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
________________________________________________________________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
_______________________________________________________________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? __________________
________________________________________________________________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
_______________________________________________________________________
Number
_____ Where is this chemical used? _______________________________________________
_____ Where is this chemical stored? ______________________________________________
_____ Briefly describe the use of this material: _______________________________________
_______________________________________________________________________
_____ How many people use this material? __________________________________________
_____ Is concentration greater than or equal to 0.1% by weight or volume? _________________
________________________________________________________________________