Place X here if renewal
Place X here if amendment
This form required by the Chemical Safety
Committee for all EXTREME and HIGH hazard projects
APPENDIX 1
Oregon State University – Environmental Health & Safety
Application/Registration for Use of Chemical Carcinogens
Choose a category of carcinogen use:
Extreme hazard carcinogen only
Extreme hazard carcinogen use and High hazard carcinogen use
High hazard carcinogen use only
1)
Date
2)
Applicant
3)
Dept
4)
Location of work:
Building
Bldg A
Bldg B
5)
Room number(s)
127, 135
234, 345
Names of all personnel participating in the project. Include employee identification number (EIN).
Place “X” in front of extreme hazard carcinogen handlers.
Name
X First Last
First Last
6)
EIN
930XXXXXX
930XXXXXX
Chemical Carcinogen/CAS number
Annual amt needed
Physical Form
e.g. chemical/XX-XX-X
600 mg
Solid
7)
Anticipated duration of project:
8)
If for course offering, list course number:
9)
Will experimental animals be used (yes or no)?
If YES:
ACUP # =
Attach Chemical Agents use in Animals form - http://oregonstate.edu/ehs/forms/auf.doc
10) Attach a brief statement of purpose and written protocol that includes methods of decontamination or
disposal of materials used.
11) For Extreme carcinogens
a. Attach written protocols, as described in section 2 of the chemical carcinogen safety manual,
that describe the project in detail. Describe which activities occur in what locations.
b. For amendments, list changes only.
c. New applicants: provide a copy of the applicant’s C.V.
Document1
UPDATED 3/18/2009
(appendix I page 2)
d. Provide evidence of medical surveillance, including pre-assignment examination, plan for or
records of periodic examinations, and any special requirements as indicated by the consulting
physician. Contact EH&S for appropriate form.
12) All use of chemical carcinogens listed in this application will be in conformance with the requirements
listed in the OSU Chemical Carcinogen Safety Manual. All personnel will read the manual and will be
adequately trained in the safe use of chemical carcinogens.
Applicant’s signature
Date
Department Chairperson
Date
13) Application/registration approved:
Chemical Safety Committee Chair – Extreme carcinogens only
Date
Office of Environmental Health & Safety
Date
Document1
Updated6/30/08