1. List each hazardous chemical and specify the highest concentration to be used as well as the location of storage and preparation or use (building and room number). Also, indicate if a Material Safety
Data Sheet is posted or present in the location(s) and personnel have been informed of that location.
(Check Yes or No) Submit a copy of each MSDS with this form.
1.
2.
Isoflurane
Hazardous Chemical
Highest
Conc.
99%
Location
Storage
Wellventilated area
Preparation/
Use
Fume Hood
MSDS
Posted/
Present
Yes
No
3.
Yes
No
Yes
No
4.
5.
Yes
No
Yes
No
Identify if the hazardous chemical is a Particularly Hazardous Substance (PHS) by checking the box of the chemical, which corresponds to the hazardous chemical line item(s) listed above. A chemical is a
PHS if it is a select carcinogen, reproductive toxin, or has a high acute toxicity. This information is available from the Material Safety Data Sheet (MSDS) or manufacturer.
Particularly Hazardous
Substance Criteria
Hazardous Chemical
(Check all that apply)
1 2 3 4 5 Select Carcinogen
Reproductive Toxin
High Acute Toxicity
1 2 3 4 5
1 2 3 4 5
2. Identify the chemicals that possess Physical Hazards. (Check all that apply. Numbers correspond to line items in #1.) This information is available from the MSDS or from the manufacturer.
Physical Hazards
Flammable
Corrosive
Hazardous Chemical
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5 Reactive
Oxidizer
Temperature Sensitive
Moisture Sensitive
Others (Specify):
Stability (e.g., decomposes, forms peroxides, polymerizes, shelf-life concerns) Check if unstable and list hazard(s).
Hazard(s):
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1
1
2
2
3
3
4
4
5
5
Known Incompatibilities: CONTACT WITH PEROXIDES
Hazardous Decomposition Products- PHOSGENE, HYDROGEN CHLORIDE, HYDROGEN
FLUORIDE.

3. Identify potential methods of human exposure to the chemicals during sample preparation and experimental manipulations. Also, identify health hazards or route(s) of entry into the body and explain how they affect the body. (Check all that apply. Numbers correspond to line items in #1.)
Method of Exposure
Aerosol generation by transfer
Mixing, shaking, or centrifuging
STAGE OF EXPERIMENT AND HAZARDOUS CHEMICAL
Preparation
1 2 3 4 5
1 2 3 4 5
Experimental Manipulation
1
1
2
2
3
3
4
4
5
5
Chemical reaction
Splash
Use of sharps (Injection)
Excretion contaminated media
Others (Specify)Anesthetic machine use
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Health Hazard/ Route of Entry
Skin Absorption/ Contact
Inhalation
Eye exposure
Ingestion
Injection (sharp objects)
Acute Effects
Chronic Effects
Hazardous Chemical
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Explain Health Hazard Effects:
ACUTE EFFECTS:
Anesthetic liquid and vapor.
May cause central nervous system damage.
Material produces anesthesia effects. Inhalation at a concentration of 0.5-3.0% can induce general anesthesia in 7 to 10 minutes, with analgesia, muscle relaxation and loss of consciousness.
Symptoms include rapid respiration, diminished mental alertness, impaired muscular coordination, faulty judgement, depression of all sensations, emotional instability and fatigue.
Isoflurane may cause a slight decrease in intellectual function and mood changes. In susceptible individuals, it may trigger malignant hyperthermia.
4. Indicate the safety controls that will be employed to minimize risk and prevent release of the agent.
(Check all that apply. Numbers correspond to line items in #1.)
EXPOSURE CONTROLS
Engineering Controls
METHOD OF CONTROL
Fume Hood
HAZARDOUS
CHEMICAL
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Biological Safety Cabinet
Glove Box
Other (Specify) Scavenging system, extendable vent
Administrative Controls Chemical handling and disposal
Sharps handling and disposal
Spill Prevention Trays used for material transfers, solution preparation, and other chemical operations.
Chemical Storage
Over-pack (chemical carriers) used when transporting solutions
Other Admin. Controls (Specify) Annual certification, exposure monitoring
Compatible, closed, & labeled container
Secondary containment
Segregated from incompatibles
Refrigerator/ Freezer
Other (Specify) Well-ventilated area
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5

Personal Protective
Equipment Use During Preparation
Gloves
*Check integrity of gloves before each use.
Safety goggles
Lab Coat
Apron
Dust Mask
Type
1
(Specify): Nitrile
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
Other: (i.e. double glove, barrier cream)
1 2 3 4 5
Specify
Describe how you will employ controls:
During Experimental
Manipulation or Animal
Handling
1 2 3 4 5
Type (Specify): Nitrile
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Specify
5. Describe the spill cleanup protocol for the maximum volume of each hazardous chemical that would be in use at any one time. Refer to, MSDSs, or guidance from EH&S for procedures. Check all that apply and explain below.
Spill kit or cleanup materials present in each lab. Specify special materials required for each chemical cleanup. Absorbent or paper towel
Personnel trained on spill cleanup procedure of each chemical and emergency contacts.
Proper personal protective equipment (PPE) available for spill cleanup. See #5 for PPE.
Emergency eyewash and/or safety shower located nearby (within 10 seconds) and unobstructed.
Personnel trained on eyewash/ shower location and operation
Eyewash/ shower inspected annually and activated weekly to verify operability.
Explain spill procedure: Ventilate area. Absorb spill and seal absorbent in bag or place in fume hood to evaporate.
6. List personnel and indicate the type of training the person has received related to the use of the chemical. Also, specify the date the person was trained and by whom, as well as the experience that person has with the chemical or procedure. Documentation that each worker has been trained in the safe use of each hazardous chemical is highly recommended.
Personnel**
Type of Training
Lab/ Chem. Safety Std. Oper. Proc.
MSDS Haz Waste Handling
Other (Specify)-
Lab/ Chem. Safety Std. Oper. Proc.
MSDS Haz Waste Handling
Other (Specify)-
Date Trained/
Conducted By
Experience
(Yrs., Type work)
Lab/ Chem. Safety Std. Oper. Proc.
MSDS Haz Waste Handling
Other (Specify)-
Lab/ Chem. Safety Std. Oper. Proc.
MSDS Haz Waste Handling
Other (Specify)-
Lab/ Chem. Safety Std. Oper. Proc.
MSDS Haz Waste Handling
Other (Specify)-
.
7. Animal Information. Specify information by filling in text boxes or checking boxes.
 Animal Species:
 Approximate number of animals exposed to chemical per year:
 Primary Housing: Cage Tank Other (Specify)

 Secondary Housing: Laboratory Room (Specify)
Animal Room (Specify)
Other (Specify)
 Special Housing Requirements: (i.e. Biological Safety Level, barrier facility)
 Room where chemical will be administered: Lapham, Pearse
 How chemical will be administered: Inhalation
 Approximate dose per animal: Max. 4%
 Frequency and duration of dosing:
 How long animal will be housed after dosing:
 Are waste products (excretion) and bedding/water considered hazardous? Yes No
 If “Yes”, specify time period after last dose is given that excretion products from the animals would be considered non-hazardous.
 Will specialized cage changing facilities (dumping stations) be required to protect the worker?
Yes No Specify, if yes:
 Will any special cleaning or decontamination be required for cleaning the cages tanks?
Yes No Specify, if yes:
Who will be responsible for cleaning, if special handling is required?
8. Describe any special disposal requirements. Refer to the Waste Disposal Guidelines or contact EH&S
(288-8411) for guidance. (Check all that apply. Numbers correspond to line items in #1.)
Chemical Disposal
Routine scheduled hazardous waste pickup
-No special disposal requirements
Neutralization
Sanitary Sewer
Other disposal: (Specify) Glass disposal, residual= evaporation
Carcass
Animal facility freezer and disposal service
Scheduled hazardous waste pickup
Other disposal: (Specify)
Excretion-contaminated Materials
(See #7 for Hazardous vs. Non-hazardous)
Hazardous Chemical
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
5
5
5
5
5
5
5
Disinfection (Specify)
Autoclave
1 2 3 4 5
1 2 3 4 5
Sanitary Sewer
Other decontamination method (Specify)
1
1
2
2
3
3
4
4
5
5
Explain disposal methods: Place empty bottles in fume hood with cap off to evaporate residual. For quantities of Isoflurane, routine, scheduled haz waste pickup.
Reviewed and Approved (Initialed) by:
Animal Care Program
Environmental Health & Safety DD