F
Sample Forms for Chemical Handling and Management

The forms in this appendix are to be used in conjunction with the guidelines for establishing a chemical laboratory safety and security program described in Chapter 3.

SAMPLE INVENTORY LOGS



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F Sample Forms for Chemical Handling and Management The forms in this appendix are to be used in conjunction with the guide- lines for establishing a chemical laboratory safety and security program described in Chapter 3. SAMPLE INvENTORY LOgS 

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TABLE F-1 Spreadsheet for Laboratory or Building  Chemical Name and Container Responsible Allowable Concentration Type Location Person Quantity Limits Hydrogen peroxide, 60% Glass 213 Lab Bldg P. Jones 4L 10 L Dichlorosilane, 100% Compressed gas 112 Lab Bldg R. Solli 11 lb 45 lb TABLE F-2 Container Inventory Chemical Location Responsible Person Authorized users Soman 215 Lab Bldg P. Jones P. Jones L. Martinez K. Liu 0 g 3 June 00 Starting Quantity: Date Received: Date Amount Removed Removed by Quantity Remaining 4 June 2009 2g K. Liu 48 grams 5 June 2009 4g L. Martinez 44 grams

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 APPENDIX F LABORATORY HAZARD ASSESSMENT CHECKLIST I. Pre-Operational Planning [ ] Toxicity What is the level of toxicity? What are the routes of exposure (inhalation, skin absorption, ingestion, injection) and which of these are likely under the conditions of use? What are the signs and symptoms of overexposure? [ ] Flammability Is the material flammable or explosive under the conditions of use? [ ] Warning Properties Can odor or irritation adequately warn of over- exposure before it becomes dangerous? [ ] Laboratory Equipment Is laboratory equipment in good condition? Are machine guards or interlocks in place and functioning? [ ] Storage Precautions Does the material need isolated storage, refrigeration or other special conditions for storage? [ ] Incompatible Materials Should certain materials be segregated (e.g., flammables and oxidizers)? [ ] Reagent Stability Should materials be dated for disposal (e.g., ethers); should materials be kept refrigerated to prolong shelf life? [ ] Protective Clothing Is a lab apron or clothing made of resistant material needed or is a lab coat adequate? [ ] Gloves What glove material is needed? Are the right type, thickness, glove length, and size available? [ ] Eye Protection What type of eye protection is needed—safety glasses for impact, chemical splash goggles for chemicals? Is a face shield needed in combination with the goggles? [ ] Heat Sources Is heating needed? Is there an alternative to open flames? Are heating mantles in good condition? [ ] Electrical Equipment Is equipment grounded properly? Are electrical cords insulated? Is ground fault circuit interruption (GFCI) needed? [ ] Vacuum/Pressure Systems Have connections been leak tested, hydrostatically tested, properly vented, and traps installed when necessary? [ ] Ventilation/Containment Does the work need to be done in a chemical hood, ventilated cabinet or a glove box to provide the needed level of containment?

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00 APPENDIX F II. Experimental Scale & Design [ ] Quantity Are there ways to minimize the amount of materials used without affecting results (e.g., microscale)? [ ] Ambient Conditions Are special conditions necessary to carry out the reaction (e.g., cold room or dry box)? [ ] Time Constraints Can the experiment be completed while lab workers are present? If not, can the experiment be safely run unattended or overnight? III. Spill/Emergency Planning [ ] Lab Personnel Are others in the laboratory aware of what you are doing? [ ] Fire Extinguishers Are special types required; are you aware of their location and proper use (e.g., Class D for metals)? [ ] Emergency Response Do you have a response planned in the event of a spill; would evacuation be necessary? [ ] Spill Cleanup Are materials on hand to absorb/neutralize; is the needed protective equipment on hand and have you been trained on its use? [ ] Safety Shower/ Are you aware of the locations Eyewash Fountain and methods of operation? Iv. Waste Disposal [ ] Method Is there an approved method for treating the waste in the laboratory? [ ] Labeling Are containers clearly, indelibly, and accurately labeled as to the contents? [ ] Segregation Are incompatible wastes kept segregated? [ ] Containers Are suitable containers with adequate closures available? [ ] Recycling Is it feasible to safely recover/recycle used chemicals?

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0 APPENDIX F SAMPLE FORM FOR SAFETY PLAN EmErgEncy PrEParEdnEss Plan for Working With a chEmical Name______________________________ Contact Information _________________________ Building ______________________________________________________________________ Supervisor _____________________________________________________________________ 1. substancE information A. Chemical name ____________________________________ CAS number _________________ B. Carcinogen Reproductive toxin High acute toxicity C. Estimated rate of use (e.g., g/month) ________________________________________________ D. MSDS reviewed and readily available Yes No 2. hazards Physical hazards A. Flammable Yes No B. Corrosive Yes No C. Reactive Yes No D. Temperature-sensitive Yes No E. Stability (e.g., decomposes, forms peroxides, polymerizes, shelf-life concerns) Stable Unstable F. Known incompatibilities ____________________________________________________________ health hazards G. Significant routes of exposure Inhalation hazard Yes No Skin absorption Yes No H. Sensitizer Yes No I. Medical consultation needed Yes No 3. ProcEdurE A. Briefly describe how the material will be used _______ __________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ B. Vacuum system used Yes No C. If yes, describe method for trapping effluents __________________________________________ [ 85 ]

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0 APPENDIX F SAMPLE FORM FOR SAFETY PLAN 4. ExPosurE controls Ventilation, isolation A. Chemical hood required Yes No B. Glove box required Yes No C. Vented gas cabinet required Yes No 5. PErsonal ProtEctiVE EquiPmEnt (PPE) (check all that apply) Safety glasses Chemical-splash goggles Face shield Gloves (type ______________) Lab coat Apron Respirator Other, please describe _______________________________________________________________ __________________________________________________________________________________ 6. location, dEsignatEd arEa A. Building _____________________________________ B. Room ________________________ C. Describe below the area where substance(s) will be used _________________________________ __________________________________________________________________________________ ______________________________________________________________ D. Location where substances will be stored ______________________________________________ E. Storage method, precautions Refrigerator/freezer Hood Special security (describe) Vented cabinet Flammable liquid storage cabinet Other, describe ___________ __________________________________________________________________________________ 7. sPills and dEcontamination A. Spill-control materials readily available Yes No B. Require special decontamination procedures? If yes, describe. Yes No __________________________________________________________________________________ 8. WastE disPosal A. In-lab neutralization Yes No B. Used up in process (e.g., no waste) Yes No C. Dispose of as hazardous waste Yes No [ 86 ]

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03 APPENDIX F SAMPLE FORM FOR SAFETY PLAN 9. authorization This person has demonstrated an understanding of the hazards of the listed substance and plans to handle the substance in a manner that minimizes risk to health and property. He/she is authorized to use the substance in the manner described. ___________________________________ __________________________________ Supervisor Chemical Safety and Security Officer 10. usE rEcord (to be completed after the material is used) A. Describe how the material was disposed of: B. Explain differences between initial planning and how material was actually used or handled. C. Are less hazardous materials available to produce the same or better results? If so, describe. D. Could the quantity or concentration used be reduced for safer handling without causing an unwanted outcome? If so, describe. E. List any recommendations for improving the health, safety or environmental impact of this process or chemical in the future. [ 87 ]

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0 APPENDIX F SAMPLE LABORATORY EMERgENCY INFORMATION SHEET Laboratory EmErgEncy information ShEEt Department Room Date Manager Responsible for Lab Office Phone Home Phone Alternate Contact Office Phone Home Phone Alternate Contact Office Phone Home Phone Emergency Coordinator: Office Phone Home Phone Building or Dept/School IN CASE OF EMERGENCY, tell your laboratory manager and call ______________. For fire, pull alarm; evacuate building; stay outside to meet with fire department official. For hazardous vapors or gases, inform others to evacuate the area; close doors; call _____________. For gases or vapors spreading to other areas, pull fire alarm; evacuate the building; WHEN IN DOUBT, GET OUT. For injuries, call _______________ for ambulance. For poison and other chemical toxicity information, call ____________. For simple spills, call ______________ for cleanup advice. Institutional Emergency Coordinator: Ambulance/Fire/Police/Spill: Hospital Emergency Room: Poison Control Center: LOCATION LOCATION Nearest Fire Extinguisher: Nearest Fire Alarm: Nearest Spill Control Material: Nearest Safety Shower: LAB LAB LAB BIOHAZARDS CHEMICALS RADIATION LOCATION LOCATION LOCATION F lammable Biosafety Level 1 Laser Low Liquid Air/Water Biosafety Level 2 Irradiator Reactive Toxics/ Rad. Sealed Biosafety Level 3 Carcinogens Source Conc. Radioactive Biosafety Level 4 High Acids/Bases Waste Pathogens: Gas Cylinders Rad. Materials Strong Human Other: Oxidizers Animal Waste Solvents Toxins Other: Other: Other: Complete and post next to your laboratory door, with a second copy next to your phone. [ 95 ]