CHEMICAL SAFETY COMMITTEE
CSC Protocol Evaluation Form
Instructions for completing the Protocol Evaluation Form
Only complete this form for:
• Chemicals listed by the International Agency for Research on Cancer
(IARC) http://monographs.iarc.fr/ENG/Classification/index.php or the National
Toxicology Program (NTP) as suspect or confirmed
carcinogens, http://ntp.niehs.nih.gov/pubhealth/roc/roc13/index.html
• Toxicological/epidemiological studies have indicated that the chemical has
reproduction hazards
• Chemicals listed as Toxic or Highly Toxic. (See
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDAR
DS&p_id=10100 for OSHA guidance on identifying Highly Toxic Chemicals).
• Known significant skin or eye irritants.
• Flammable, air reactive, or water reactive chemicals.
• Corrosive chemicals in concentrations of one (1) molar or greater.
• Acute, and or reactive hazard(s),
• Exhibit physically dangerous characteristics such as explosive, pyrophoric, or
poisonous.
1. Complete all parts of this form.
2. All investigators require CSC approval before starting procedures. Remember that all
research projects utilizing human subjects, chemicals, experimental animals or
radioactive materials MUST obtain the approval of the IRB, IBC, IACUC or Radiation
Safety Committee, respectively.
3.
Incomplete Protocol Evaluation Forms that do not have all the required
documentations will not be evaluated until they are completed.
6. Do not forget that you must submit a list of chemicals used, hazardous and otherwise,
and declare their categories. Some commonly overlooked hazardous materials used in
many molecular biology labs are: acrylamide monomer, ethidium bromide and
formaldehyde. Please examine your methods thoroughly and report all hazardous
chemicals used in the protocol.
7. Examine your protocol carefully for radioisotope use. RIA and PCR frequently involve
isotope use and should be reported.
9. Make sure to sign the “Acknowledgement of Responsibility and Knowledge”.
Version Date: April 8 2015
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CSC Protocol Evaluation Form
Date Received: ____________________
Universal Number: _________________
From:_____________ to:_____________
__________________________________
CSC Chairperson
Section 1 - Applicant Data
Project Name: ________________________________________
Principal Investigator: _________________________________
Department: _________________________________________
Office Phone: ________________________________________
Other Committee Approvals:
Section 2 - Identification of Chemical Agent
Quantity and number of times a procedure is performed helps determine the risk of an
accident happening and the possible severity of the incident.
Chemical Agent:
Max Quantity/Concentration use:
Minimum Quantity/Concentration use:
Number of times the procedure will be performed: (Example: once daily)
Storage Quantities and Location:
Location Where Work is to be Conducted (Building/Room Number):
Laboratory Phone Number:
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Section 3 – For UCC Personnel Involved In The Study Indicate The Experience
Working With Chemical Agents / Experience With The Specific Agent Under Review
1.
2.
3.
Experience:
Experience:
Experience:
/
/
/
Section 4 – Brief Experimental Description (Include procedural aspects regarding
chemical usage, what are the highest risk steps in the experiment):
Methods:
Section 5 – Chemical / Industrial Hygiene Related Information
Physical Properties:
Classification:
Toxicology:
Routes of Exposure:
Other Precautions:
Exposure Limits:
Monitoring Requirements:
Section 6 - Hazard Controls
Engineering/Administrative Controls:
Personal Protective Equipment:
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Section 7- Hazardous Waste Disposal
Identify method of waste disposal:
Hazardous waste code:
Has source substitution been investigated?
Can chemical be neutralized during experiment?
Version Date: April 8 2015
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FOR OFFICIAL USE ONLY
COMMITTEE MEMBER
NAME
COMMITTEE MEMBER
SIGNATURE
COMMENTS
Misty Eaton, PhD
Mikhail Inyushin, PhD
Alexander Vasin, PhD
Janaina Alves, PhD
Ileana M. Cortés
ACTION
Approved
Meredith Herrera
Chair of Chemical
Safety Committee
Version Date: April 8 2015
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Approved with
modifications
Disapproved
Date
(mm/dd/yyyy)
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