Name of User

Record of Use of known Hazardous Chemicals – CMR form SOM029

Name of User: Status: M / F Email: Office Location / Phone No. Student Number: Supervisor: Contact details:

Work Activity: School of Materials Unit: Location(s): Tel. No. Materials / Paper / Textiles / Seen by Supervisor signature and date

Form used: Relevant Chemical Name Cas No. Details of Use: Liquid / Safety Approx quantity used / rate of use powder / Assessments Used in Lab(s) Safety Date: Lab: Risk Level crystals Phrases Chemical Cas

H R Date: Lab: Low / Med / High Chemical Cas

H R Date: Lab: Low / Med / High

Chemical Cas

H R Date: Lab: Low / Med / High Risk Date: Lab: Low / Med / High Chemical Cas

Chemical Cas

Review after any incident and at least every 6 months – (more often, depending on the hazard and risk) Review Incidents Comments Review Incidents Comments Review Incidents Comments Date Date Date

MSDS - Carcinogen – R40, R45, R49 ║ Reproductive Toxin – R60, R61 ║ Mutagen – R46 ║ Sensitiser – R42, R43 ║ Natal – R62, R63, R64 SDS - Carcinogen – H350, H351 ║ Reproductive Toxin – H360, H361 ║ Mutagen – H340, H341 ║ Sensitiser – EUH203, EUH204, EUH205, EUH208, H334 ║ Natal – H362 Also any chemical officially listed on Poison EUH201, EUH201A, EUH207,H304, H310, H330 Drug Precursor, Explosive or Chemical weapon list To be completed by User and local named person Record of Use of known Hazardous Chemicals – CMR form SOM029 This table to record all relevant information – i.e. training, near misses, incidents etc. Date Comments

MSDS - Carcinogen – R40, R45, R49 ║ Reproductive Toxin – R60, R61 ║ Mutagen – R46 ║ Sensitiser – R42, R43 ║ Natal – R62, R63, R64 SDS - Carcinogen – H350, H351 ║ Reproductive Toxin – H360, H361 ║ Mutagen – H340, H341 ║ Sensitiser – EUH203, EUH204, EUH205, EUH208, H334 ║ Natal – H362 Also any chemical officially listed on Poison EUH201, EUH201A, EUH207,H304, H310, H330 Drug Precursor, Explosive or Chemical weapon list To be completed by User and local named person