Carc Program Appendix 1

Place X here if renewal This form required by the Chemical Safety Place X here if amendment Committee for all EXTREME and HIGH hazard projects APPENDIX 1

Oregon State University – Environmental Health & Safety Application/Registration for Use of Chemical Carcinogens

Choose a category of carcinogen use: Extreme hazard carcinogen only Extreme hazard carcinogen use and High hazard carcinogen use High hazard carcinogen use only

1) Date

2) Applicant

3) Dept

4) Location of work: Building Room number(s) Bldg A 127, 135 Bldg B 234, 345

5) Names of all personnel participating in the project. Include employee identification number (EIN). Place “X” in front of extreme hazard carcinogen handlers.

Name EIN X First Last 930XXXXXX First Last 930XXXXXX

6) Chemical Carcinogen/CAS number Annual amt needed Physical Form

e.g. chemical/XX-XX-X 600 mg Solid

7) Anticipated duration of project:

8) If for course offering, list course number:

9) Will experimental animals be used (yes or no)? If YES: ACUP # = Attach Chemical Agents use in Animals form - http://oregonstate.edu/ehs/forms/auf.doc

10) Attach a brief statement of purpose and written protocol that includes methods of decontamination or disposal of materials used.

11) For Extreme carcinogens a. Attach written protocols, as described in section 2 of the chemical carcinogen safety manual, that describe the project in detail. Describe which activities occur in what locations. b. For amendments, list changes only. c. New applicants: provide a copy of the applicant’s C.V. d. Provide evidence of medical surveillance, including pre-assignment examination, plan for or records of periodic examinations, and any special requirements as indicated by the consulting

D:\Docs\2018-04-14\03f033182084fde7856a89e922cdcb0f.docx UPDATED 3/18/2009 physician. Contact EH&S for appropriate form.

12) All use of chemical carcinogens listed in this application will be in conformance with the requirements listed in the OSU Chemical Carcinogen Safety Manual. All personnel will read the manual and will be adequately trained in the safe use of chemical carcinogens.

Applicant’s signature Date

Department Chairperson Date

13) Application/registration approved:

Chemical Safety Committee Chair – Extreme carcinogens only Date

Office of Environmental Health & Safety Date

D:\Docs\2018-04-14\03f033182084fde7856a89e922cdcb0f.docx Updated6/30/08