University of South Australia
CHEMICAL HAZARDS APPLICATION FORM
Application for approval to use hazardous substances for research purposes
Chemical hazardous substances are defined as pathogenic, carcinogenic or teratogenic substances, or any highly
toxic chemical that require special precautions to be taken in its use or storage.
This application is for the use of a Carcinogenic, teratogenic or highly toxic chemical including
 Cytotoxic Drugs
 IARC Monographs Group 1&2 Carcinogens
 Heavy Metals
 Chemicals with a ChemWatch chronic or toxicity health risk rating of 4.
Projects which propose the use of large amounts of chemicals with a relatively low toxicity (risk rating of 3 or below)
should also be approved before their commencement.
(Application assessed by the Chemical Hazards Subcommittee)
When completed please forward this form as an attachment to:
researchcompliance@unisa.edu.au
or mail to:
Chemical Hazards Subcommittee
Research and Innovation Services
University of South Australia
General Purpose Building
Mawson Lakes Campus
Mail code IPC – MLK-29
If you require any information or assistance in completing this form, please contact Dr Euan Smith (8302 5042).
1.
2.
Project title (Short descriptive title of no more than 20 words in length)
Justification Clearly justify why the chemical is to be used. The summary should be intelligible to a lay reader, and
presented in clear and concise terms.
3.
Individuals that will be handling the chemical hazardous substances
3.1 Investigators: Academic, research or technical staff
1st Chief Investigator
Other Investigator
Other Investigator
Title (eg Prof, A/Prof, Dr)
Initials and surname
Current appointment
Department/school/other
Is this person
Male
Female
Male
Female
Male
Female
3.2 Will any students be using the chemical hazardous substances?
Yes
No
If yes, please attach a list of students' names.
3.3 Is the research for teaching or research purposes?
4. Chemical hazardous substances for which the Chief Investigator is seeking approval for use
Chemical name
Physio-Chemical Form
(eg liquid, powder, % solution)
Total amount to be
located at site
5. A description of the toxicity of the chemical substances to be used
6. A risk assessment of the process in which the chemical substance(s) are to be used MUST BE
COMPLETED AND ATTACHED TO THE APPLICATION FOR APPROVAL
The risk assessment process for Chemical hazardous substances can be found at:
http://w3.unisa.edu.au/ohsw/forms/docs/ohsw12.docx
From the risk assessment include a brief description of how the chemical hazardous substances will be
used. Include comment on:
(a) Where the experiments using hazardous substances are to be conducted.
(b) What facilities are available for the safe handling of the substances.
(c) The concentration of the substances used in experiments.
(d) What safety precautions will be taken.
(e) A concise description of the experimental methodology.
7. Anticipated start date of project
7a. Period of use of the chemical hazardous substances. Please tick one box.
< 1 week
1 -12 weeks
> 3 months
1-2 years
3 years*
* Please note that ethics approval can only be given for a maximum of three years. If the project is expected to
take longer than this time, you will need to submit another application before the 3 year expiry date.
8. How will the chemical substances or their products be disposed of
a) during the period of experimentation?
b) after conclusion of all planned experiments?
9. References relevant to the dangers or safe use of the chemical substances to be used
(Attach separate list if necessary or copies of key references.)
10. Compliance with guidelines and statement of responsibility
I certify that I am aware of and have access to the ‘Guidelines for the use of carcinogenic and/or toxic
chemicals’; that I will take responsible care with the use of the chemicals specified in this application, and that
all involved staff and students will be properly instructed in the safe use and disposal of these substances.
Signed:
(Chief Investigator)
Date:
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11. Certification by Head of School/Unit/Department
I certify that the project described in this application can be accommodated within the general facilities of my
department and that appropriate facilities and procedures are in place for safe use of the substances
specified.
Signature:
Date:
Name (please print):
Position:
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