John Jay College Of Criminal Justice Environmental Health And

john jay college of criminal justice, environmental health and safety annual hazardous material screening survey instructions: faculty who

John Jay College of Criminal Justice, Environmental Health and Safety
Annual Hazardous Material Screening Survey
Instructions: Faculty who have been assigned a Research Lab should
complete this form and return it to Natalya Timmer,
[email protected].
1a. Name:
1b. Email:
1c: Best emergency contact phone number:
1d. Laboratory rooms you responsible or partially responsible for:
2.
Do you/will you prepare packages containing dry ice or other
dangerous goods to be mailed? ___ Yes ___ No
3.
Do you plan to obtain, or currently use or store any of the
materials listed below? Check all that apply.
___Human Blood, other body fluids or tissues, cells or cell lines
___Non-Human Primate blood, body fluids, tissue or cells or cell line
___ Infectious Agents; bacteria, viruses, fungal, prions, etc.
(Extensive CDC & NIH requirements for some)
___ HHS and USDA Select Agents and Toxins More Info (Extensive
government security approval process)
___Agents that may require a permit
___Recombinant DNA or RNA use, genetic recombinant techniques,
complete molecules, or organisms,
transgenic organisms, plants, animals? More Info (IBC approval might
be necessary)
___ Radionuclides (Extensive authorization process)
Controlled substances (drugs/pharmaceuticals) (Not Allowed at this
time)
Vertebrate animal or cephalopod (Not Allowed at this time)
2.
Do you plan to obtain, or currently use or store any of the
materials listed below? Check all that apply.
Chemicals with GHS Rating of 1 for: ___ Acute Toxicity, ___
Respiratory Sensitizer, ___Reproductive Hazard Chemicals with GHS
Rating of 1 for ___ Reactivity, ___ Oxidizer, ___ Pyrophoric, ___Self
Reactive
2.
Are you using or planning to or use any unusually dangerous or
hazardous procedures or materials that have not been mentioned
above? ____ Yes ____ No
3.
If you checked any items in #3 or #4, or indicated yes, in #5,
please explain your answers using the space below. Describe if the
materials will be used in the future or if they are used or stored
now.
Employee’s Attestation: The above answers are true. I understand that
in the future I must notify the Science Department Laboratory
Director, Natalya Timmer, via [email protected], in advance of
ordering hazardous materials listed above that are not currently used
or stored.
Name (Print or Type): __________________________________ Title:
_____________________________
Name (Signature): __________________________________ Date:
_____________________________