CHEMICAL USAGE QUESTIONNAIRE
Date:
Chemical Name & CAS #:
Training taken (i.e. annual lab safety, bloodborne pathogens):
Emergency Phone Number:
Requestor:
475-3333
Number of Potential Users: (list names)
Physical State of Chemical:
Gas
Liquid
Solid
mLs or L
Storage of Chemical:
Exhausted
Chemical
°F Cabinet
Cabinet
Ambient
2.
3.
4.
Dept. Name:
Amount Used per Procedure:
Temperature of Procedure:
1.
Phone:
°C
How is the chemical used in
the laboratory? (details of the
process)
What are the handling and
disposal procedures?
Is the chemical used in a
posted regulated area in the
lab? (signage and MSDS/SDS)
What personal protective
equipment (PPE) is used for
the operation?
Rm #:
Floor:
Bldg:
Hood:
Frequency of Use:
g or Kg
x a day
x a week
x a month
Amount of Chemical Stored:
Other:
Cylinders
mL or L
g or Kg
>
>
Yes ___
Comment, if needed.
No ____
Gloves:
Eye Protection:
Nitrile
Neoprene
Latex
N. rubber
Face shield
Goggles
Glasses w/
side shields
Protective
Clothing:
Lab Coats
Aprons
Tyvek Suits
Other types:
Respirators:
Supplied Air
Full face
Half face
Disposable
Other:
5.
What engineering controls
are used?
6. Are there applicable buddy
system requirements?
(if yes, indicate tier)
Exhaust Type:
Exhaust operational: (Y or N)
Date of
Certification:
Flow Rate:
Certified hood
Balance
enclosure
Local exhaust
Is emergency safety equipment in vicinity? Where are they located (i.e.. eye wash, safety
shower, fire extinguisher):
Yes ___ No ___
Comments:
Tier 1 ______
Tier 2 _____
Tier 3 ______
Tier 4 _____
*RIT EH&S must be notified of any changes that would increase employee exposure to these chemical(s).
This section to be completed by RIT EH&S:
Is representative exposure monitoring data available?
Rational:
Comments:
Anticipate Exposure:
< AL
>AL <PEL
>PEL/TLV
> STEL
>Ceiling
Yes
No
Approved by
By:
CHO:
YES
NO
Date: