<p> Supplemental Hazardous Materials, Risk Assessment</p><p>Instructions: If applicable, submit this form with Animal Use Protocol (AUP). (PLEASE SINGLE CLICK ON SHADED BOXES TO TYPE)</p><p>1.Description of hazardous material</p><p> a. Hazard (fill in applicable information): </p><p>Chemical (name) Route of toxicity (e.g. inhalation) Type of toxicity (e.g. irritant) Biohazard (name) Route of infection (e.g. inhalation) Biohazard level (e.g. BSL-1) Radioisotope (name) Route of administration Physical hazard (e.g. UV light) Route of administration Other (describe) Route of administration</p><p> b. Description of hazardous material: (form upon receipt, solubility, volatility, vehicle, etc.): </p><p> c. If applicable, Manufacturer: Product #: </p><p> d. Where will the material be stored prior to use (room, refrigeration, etc.)? </p><p> e. Submit a material data sheet if commercially available (submit as an e-mail attachment).</p><p>2.Proposed use of hazardous material in animals</p><p> a. Animal species to be dosed: </p><p> b. Proposed work location: </p><p> c. Dose per animal: </p><p> d. Route of delivery: </p><p> e. Treatment schedule: </p><p> f. Time treated animals will be maintained: </p><p> g. Number of animals to be treated for each experiment: 3.Fate of hazardous material (where does the compound go after dosing the animal?)</p><p> a. Route of excretion: </p><p> b. What is excreted: </p><p> c. Percent excreted: </p><p> d. Where is the hazard? How long is it present? Describe where the hazard exists and how it should be handled:</p><p>4.Institutional approvals for using hazardous materials</p><p> a. Institutional Biosafety Committee (IBC) a.i. IBC Protocol Number: a.ii. Date of IBC approval: </p><p> b. Radiation Safety Committee (RSC) b.i. Date of RSC approval: </p><p>5.Exposure Risk Management</p><p> a. Preparing hazardous material a.i. Where will hazardous material be prepared (lab, room, fume hood, BSC)? </p><p> a.ii. Lab door signage will read: </p><p> a.iii. Required PPE for preparation: </p><p> a.iv. Clean-up procedures: </p><p> a.v. Waste disposal procedures:</p><p> b. Exposing animals to hazardous material</p><p> b.i. Where in vivaria will animal work be conducted? </p><p> b.ii. Animal room signage will read: </p><p> b.iii. Required PPE for research staff: </p><p> b.iv. Clean-up procedures: </p><p> b.v. Waste disposal procedures: </p><p> c. After exposing animals to hazardous material c.i. Time frame (how long will animals be kept following exposure): </p><p> c.ii. Animal room signage will read: </p><p> c.iii. Required PPE for research staff: </p><p> c.iv. Required PPE for LAB staff: </p><p> c.v. Cage changing frequency: </p><p> c.vi. Bedding disposal procedure: c.vii. Carcass disposal procedure: </p><p> c.viii. Waste disposal procedure: </p><p> d. Termination of hazardous experiment in animals d.i. Time frame (how long will hazard be present): </p><p> d.ii. Animal room signage will read: d.iii. Required PPE for research staff: d.iv. Required PPE for LAB staff: </p><p> d.v. Cage changing frequency: d.vi. Bedding disposal procedure: d.vii. Carcass disposal procedure: </p><p> d.viii. Waste disposal procedure: </p><p> e. Action to take if you have an accidental exposure to hazardous material e.i. Needle stick, other sharp: </p><p> e.ii. Skin or mucous membrane exposure: e.iii. Where to seek medical attention: </p><p> e.iv. File an accident report: </p><p> f. Drugs, antidotes, or immunizations available to hazardous material f.i. Drugs and dosage: f.ii. Antidotes and dosage: </p><p> f.iii. Immunization: </p><p>6.For IACUC use only: date and name of person reviewing hazard information including comments</p><p> a. Environmental Health & Risk Management: </p><p> b. Biosafety Officer: </p><p> c. Occupational Health and Safety: </p>