CONTRACTOR'S HAZARDOUS CHEMICALS IDENTIFICATION FORM
Iowa State University
Notification of Hazardous Chemicals and Appropriate Personal Protective Measures for Contractual Work to be
conducted. (Iowa Administrative Code, 875, Chapter 110).
RE: Contractual work being conducted by
for
Contractor
Use project title exactly as on Award Letter or Contracts
State the known hazardous chemicals used by the Contractor and/or associated with the work being conducted.
Continue list on a separate sheet if necessary.
State the appropriate protective measures (e.g. personal protective equipment) necessary to avoid the effects of
these hazardous chemicals. Continue list on a separate sheet if necessary.
I certify that the above information is correct and complete.
Contractor's Representative
Signature
Date
Title
Acknowledge receipt of form.
ISU’s Representative
Signature
Date
Construction Manager, Facilities Planning and Management
c:
Contract Administration, Facilities Planning and Management
Environmental Health and Safety
TO BE FILLED OUT BY CONTRACTOR'S REPRESENTATIVE
Please complete, sign, and return to: Iowa State University, Facilities Planning and Management, Contract
Administration, 2nd Floor General Services Building, Ames, IA 50011-4021. A fully signed document will be made
available to the contractor.
Note: The Contractor is responsible for submitting a copy of this form by registered mail to the fire
department. For projects located on the ISU campus, send to: Ames Fire Department Headquarters,
Attention Deputy Chief, 1300 Burnett Avenue, Ames, IA 50010. For projects in locations other than ISU,
send to the local fire department.
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