Chemical Hazard Worksheet
Complete this worksheet to identify:
1. Substances that require approval prior to acquisition and use.
2. The individuals who need to assess exposure to each chemical substances used; and
3. Hazards that need to be addressed and controlled to protect individuals working with or near
the chemical substances. The control measures used to control the hazards need to be written
into the Standard Operating Procedure (SOP) for the work. Note: the SOP should bear the same
name as the title given below.
Title of Work:
Location:
Supervisor:
Date:
-An example is provided at the end of this worksheet -
SUBSTANCES REQUIRING APPROVAL PRIOR TO ACQUISITION & USE - Before performing the following
steps you must make sure that none of the chemical substances you are planning to use include those
requiring approval by the college Health& Safety Officer or Risk Management prior to use. This includes
radioactive substances and any substance for which there is a corresponding asterisk, which are also
highlighted in the table found in Step 4 below (cross reference Section 2 of your SDS’s).
Step 1 - Make sure you have all of the Safety Data Sheet(s) for the chemical substances you will be
using during your work. You have to use Safety Data Sheets (SDS), not Material Safety Data Sheets
(MSDS). If you don’t have the SDS’s then you’ll need to obtain them from the manufacturers – see their
website or call them.
Step 2 - Using your SDS’s fill-in the applicable information into the table:
a. Check the Hazard Category (HC) box that corresponds with the lowest value Hazard
Category found in section 2 of the Safety Data Sheet (ignore letter designations). Note:
lower numbers indicate a higher hazard in the GHS system.
b. The Duration Factor (DF) for use of each substance. Please indicate how long the
chemical is used during each period of use by selecting the DF that best matches (select
Duration Factor from those listed below the table)
c. The Frequency Factor (FF) for use of each substance. Please indicate how often the
chemical substance is used, by selecting the FF that best matches (select Frequency
Factor from those listed below the table)
d. Calculation. Calculate the following for each substance: (HC x DF) / FF.
1
Name of Chemical
Substance (as found on SDS)
Hazard Category (HC)
1
2 3
4
5
  
 
  
 
  
 
  
 
  
 
Duration
Factor (DF)
Hazard Categories (HC)
1 = High hazard
2 = Medium-high hazard
3 = Medium-low hazard
4 = Low hazard
5 = Low hazard
Duration Factors
1 = close to 8 hours
1.2 = close to 6 hours
2.4 = close to 4 hours
3.6 = close to 2 hours
4.8 = close to 1 hour a day or less
Frequency
Factor (FF)
Calculation
(HC x DF) / FF =
Frequency Factors
1 = one or more times a day
0.75 = a few times a week
0.5 = a few times a month
0.25 = less than once a month
Step 3 - Identifying Who Needs to Evaluate Exposure to Chemical Substance(s)
Using your Calculation results above determine which substances need to be evaluated by you, your
supervisor, and/or the college Health & Safety Officer. To make this determination compare your
Calculation results for each substance with the following information:
Step 4 - Identifying Chemical Hazards That Need To Be Controlled
Hazards – using the Hazard Classifications found on the SDS’s mark the applicable boxes below. Note:
sometimes the Hazard Class is abbreviated or there is some ambiguity, so the associated classification
code and Hazard Category codes have also been provided.

Safety Hazard Class
Explosives

Flammable Gases

Flammable Aerosols

Flammable Liquids


Flammable Solids
Self-Reactive Substances &
H200
H201
H201
H203
H204
H205
H220
H221
H222
H223
H224
*
*
*
*
*
*
1
2
1
2
1
H225
H226
H227
2
3
4
H228
H240
1 or 2
*

Health Hazard Class
Acute Toxicity, Oral

Aspiration Hazard

Acute Toxicity, Dermal

Skin Corrosion / Irritation


Sensitization, Skin
Serious Eye Damage / Eye
Irritation
H300
H301
H302
H303
H304
H305
H310
H311
H312
H313
H314
H315
H317
H318
*
*
4
5
1
2
*
*
4
5
1A, B,
or C
2
1
1
H319
H320
2A
2B
2
Mixtures; & Organic
Peroxides



Pyrophoric liquids,
Pyrophoric Solids
Pyrophoric Gases
Substances and Mixtures
which, in Contact with
Water Emit Flammable
Gases

Acute Toxicity, Inhalation
*
1

Respiratory Sensitization
H261
2 or 3

H241
H242
H250
*
*
*
H260

Oxidizing Gases
H270
1


Oxidizing Liquids; Oxidizing
Solids
H271
1

Specific Target Organ
Toxicity, Single Exposure;
Respiratory Tract Irritation
Specific Target Organ
Toxicity, Single Exposure;
Narcotic Effects
Germ Cell Mutagenicity
Gases Under Pressure

Carcinogenicity

Corrosive to Metals
H272
H280
H281
H290
2 or 3


Reproductive Toxicity

Reproductive Toxicity,
Effects on or via Lactation
Specific Target Organ
Toxicity, Single Exposure
1

H330
H331
H332
*
*
*
H333
H334
*
1
H335
3
H336
3
H340
1A or
1B
2
*
2
1A or
1B
2
H341
H350
H351
H360
H361
H362
H370
1
H371
H372
2
1
H373
Note: a line for “Other” Category is provided since there are some EU designations that may show up
*Requires approval from Risk Management & Dean’s Office before obtaining or using this substance
2

Specific Target Organ
Toxicity, Repeated Exposure
Step 5 - If another individual performed an assessment of the use of a chemical substance make sure
to collect their findings and include it with this completed form.
Step 6 - Using the resources available to you (including your supervisor, the college Health & Safety
Officer, and Risk Management) identify what measures you will implement to protect individuals from
the chemical hazards associated with your work.
Step 7 - Attach this completed form and completed chemical use assessments to your written
Standard Operating Procedure (SOP) for the work being performed. And, make sure your SOP identifies
the hazard control measures you will use to protect yourself and others while the work is being
performed.
Step 8 - Review this assessment and your SOP at least annually, and anytime the work changes.
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-ExampleStep 1:
the Safety Data Sheet for Piranha 4 No. 5740 and Acetone were obtained. Section 2 from each
SDS indicates:
Piranha 4 No. 5740
Acetone
Step 2: enter the applicable information into the table, and perform the calculation
Name of Chemical
Substance (as found on SDS)
Piranha 4 No. 5740
Acetone
Hazard Categories (HC)
1 = High hazard
2 = Medium-high hazard
Hazard Category (HC)
1
2
3
4




















Duration Factors
1 = close to 8 hours
1.2 = close to 6 hours
Duration
Factor (DF)
1.2
4.8
Frequency
Factor (FF)
1
1
Calculation
(HC x DF) / FF =
1.2
9.6
Frequency Factors
1 = one or more times a day
0.75 = a few times a week
4
3 = Medium-low hazard
4 = Low hazard
2.4 = close to 4 hours
3.6 = close to 2 hours
4.8 = close to 1 hour a day or less
0.5 = a few times a month
0.25 = less than once a month
Step 3: based on the calculation the Health & Safety Officer needs to evaluate the exposure to
Piranha. The Health & Safety Officer performed this evaluation.
Step 4: Based upon the Hazard Classifications found on the SDS the following hazards were identified

Safety Hazard Class
Explosives

Flammable Gases

Flammable Aerosols

Flammable Liquids


Flammable Solids
Self-Reactive Substances &
Mixtures; & Organic
Peroxides

Substances and Mixtures
which, in Contact with
Water Emit Flammable
Gases


Oxidizing Gases
Oxidizing Liquids; Oxidizing
Solids

Gases Under Pressure
H200
H201
H201
H203
H204
H205
H220
H221
H222
H223
H224
*
*
*
*
*
*
1
2
1
2
1
H225
H226
H227
2
3
4
H228
H240
1 or 2
*
H241
H242
H260
*
*
1
H261
H270
H271
H272
H280
H281

Health Hazard Class
Acute Toxicity, Oral

Aspiration Hazard

Acute Toxicity, Dermal

Skin Corrosion / Irritation


Sensitization, Skin
Serious Eye Damage / Eye
Irritation

Acute Toxicity, Inhalation
2 or 3
1
1


2 or 3

Respiratory Sensitization
Specific Target Organ
Toxicity, Single Exposure;
Respiratory Tract Irritation
Specific Target Organ
Toxicity, Single Exposure;
Narcotic Effects
Germ Cell Mutagenicity

H300
H301
H302
H303
H304
H305
H310
H311
H312
H313
H314
H315
H317
H318
1 or 2
3
4
5
1
2
1 or 2
3
4
5
1A, B,
or C
2
1
1
H319
H320
2A
2B
H330
H331
H332
1 or 2
3
4
H333
H334
H335
5
1
3
H336
3
H340
1A or
1B
2
H341
5

Corrosive to Metals
H290
1

Carcinogenicity
H350

Reproductive Toxicity
H351
H360

Reproductive Toxicity,
Effects on or via Lactation
Specific Target Organ
Toxicity, Single Exposure


Other:

Specific Target Organ
Toxicity, Repeated Exposure

Other:
H361
H362
1A or
1B
2
1A or
1B
2
H370
1
H371
H372
2
1
H373
2
Step 5: the exposure assessment information was collected that pertains to use of Piranha. It is kept
with a copy of this completed Chemical Hazard Worksheet and the corresponding Standard Operating
Procedure (SOP).
Step 6: A meeting was help with the research group and supervisor to discuss each hazard identified in
the table above. The discussion addressed the recommendations provided by the Health & Safety
Officer and how they will be incorporated into the work to be performed. The meeting resulted in
identifying control measures to be included in the SOP for the work
Step 7: A written SOP for the work was created and appended it with this completed worksheet and
the exposure assessment performed by the Health & Safety Officer
Step 8: The assessment and SOP will be reviewed a year from the SOP completion date to make sure
the controls are adequate.
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