Initial Application • CampusOptics

Please complete and provide as much information as possible. You are able to add documentation at the bottom under, "Add Documents".

Applicant Info

Email Address* Required

Phone Number

First Name* Required

Last Name* Required

Basic Information

Application Type

Title* Required

Principal Investigator* Required

Additional Investigators

Associated Research Labs

PI Information

Department* Required

Name of PI/Emergency Contact* Required

Phone Number* Required

Emergency Number* Required

Animal Use Information

Will live animals be used in ths study?* Required

Chemical Safety Information

Chemical Name* Required

CAS#* Required

Quantity used (g, kg, mL, L, % solution) per day in the lab; frequency used* Required

Physical Form* Required

Solid

Liquid

Gas

Routes of Entry* Required

Eyes

Skin

Inhalation

PPE to be used* Required

Chemical Fume Hood Required?* Required

Respirator or Other Respiratory Protection Used?* Required

If "Yes", indicate type of respirator/protection. *Respirators require OHP fit-test and approval prior to wear.* Required

SDS Available in Lab Electronically or Paper Format* Required

Electronic

Paper

Procedures

List all procedures the chemical will be used for. A separate document can be attached under "Add Supporting Documents".* Required

Waste Disposal Procedures

Explain disposal process for chemicals used* Required

Emergency Response & Training

Hazard Communication and General Lab Safety Training* Required

Hazardoous Waste Generator Training* Required

Specific Hazard Chemical Training by PI* Required

Was Emergency Response Exposure Information for the Chemical Covered?* Required

Additional Notes

Notes

Principal Investigator/Laboratory Manager Statement of Assurance

You agree that all lab members will recieve instruction on the safe handeling, use, containment, proper disposal, and handling of personal injuries or accidental exposures of the listed chemical in this document.

Add Supporting Documents

Add files to upload as supporting documentation.