This form is to be filled out for chemicals that are ordered for the "FIRST TIME" by a department. It is meant to insure that Material Safety Data Sheets (MSDS's) are available, and that all safety equipment and regulatory issues are in place prior to the chemical arriving on campus. It is not intended to prohibit the ordering of any chemical by employees but rather to assure that the University and its employees are complying with all pertinent legislation regarding the acquisition of chemicals. Thank you for your cooperation in filling out this form. Should you have any questions regarding your chemical order, please call the Chemical Management Center at Extension 3703.

Responsible Individual___________________________________________ Department__________________

Extension____________ Date Requested_________________ Date Needed_________________

Name of Chemical Substance_____________________________________________________________________

Amount to be ordered______________________ How long will chemical be used?_________________

Chemical Company__________________________________ Catalog Number_____________________

Storage Requirements (Check) Engineering Controls Needed (Check if applicable)

General Chemical Storage                  Chemical Fume Hood

Cool               Dry           Cabinet                         Perchloric Acid Hood

Refrigerator                          Distillation Hood

Freezer                           Laminar Flow Hood

Explosion Proof Refrigerator                             Glove Box

Flammable Cabinet Other (describe)__________________________

Corrosive Cabinet

Inert Atmosphere

Other (describe)_________________

Personal Protective Equipment Special Labeling Requirements (check if applicable)

(check all that are appropriate) Carcinogen

Protective eyewear (ANSI Z87.1) Teratogen

Face shield Mutagen

Gloves Embryotoxin

Lab Coat Lacrymator

Respirator (call EOHS prior to issuing) Reproductive Hazard

Other (describe)____________________ Other (describe)___________________

Is employee exposure anticipated? No Yes (amount)______________________

Are workplace exposure levels anticipated? No Yes (amount)______________________

Comments:

__________________________________________________ ________________________
Signature of Responsible Individual                                                                          Date

Distribution: Original - Responsible Person Copy - CMC Revised September 1998