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SLAC National Accelerator Laboratory

Hazards Form

The following information must be provided for each hazardous substance brought to SSRL. A hazardous substance is anything that is ignitable, corrosive, reactive, toxic (including carcinogens) radioactive* or biologically hazardous.


This form must be submitted one month prior to your experiment run. Following receipt of this form, you may receive a Safety Review Summary Form which must be signed and returned 2 weeks before your experiment is scheduled to begin. If this documentation is not completed promptly, the start of your experiment will be delayed.   I


Include one copy of all relevant MSDSs. Include the proposal number and spokesperson's name at the top of each MSDS.




General Information 
Spokesperson  Proposal No.
Scheduled Dates Beam Line
Contact E-mail
CHEMICAL USE? yes no
If yes, list substances and complete a hazard form(s) for each substance.

Substance
Common Name
Chemical Formula
Total Amount
Form
(solid, liquid,
gas, powder)

NANOSCALE MATERIALS USE? yes no
If yes, will there be open manipulation of nanoscale material samples at SSRL? yes no

If no, how are the samples contained?

If yes, a safety plan must be submitted to the SSRL Safety Office for approval. See CDC/NIOSH website for guidance. http://www.cdc.gov/niosh/topics/nanotech/safenano/


BIOHAZARDOUS MATERIALS USE? yes no
If yes, what type and what is the materials NIH classification?


HUMAN OR ANIMAL SUBJECT USE? yes no
If yes, what type? *Please contact SSRL Safety Office for further guidance.


RADIOACTIVE MATERIALS USE? yes no
If yes, what is the materials specific activity?

*Radioactive substances may not be brought directly to SSRL. They first must be shipped or taken to Operational Health Physics, Bldg. 24, MS 84, 2575 Sand Hill Rd., Menlo Park, CA 94025; please contact Carol Morris at 650-926-3023 or Jim Allen at 650-926-4064.


Use/Procedure
 

What is your intended use?
Will the substance be reacted while at SSRL? yesno
What are the reaction products? (Include MSDS for each product.)
How is the substance contained?
How will it be shipped to SSRL?
Will the substance be transferred from one container to another at SSRL?
Where will the substance be used at SSRL?
Where will the substance be stored when not in use at SSRL?
What specific dates will this substance be at SSRL?

What quantity of waste will be generated and in what form? (include contaminated cloths, wipes, containers, etc.)


How do you plan to dispose of this substance and its reaction products?


How do you plan to clean or dispose of containers, sample holders, utensils, etc. that have been exposed to the substance?


What special precautions are you planning to take to prevent exposure to yourself and others?


What precautions should SSRL implement?


Has this procedure been reviewed by the safety organization at your home institution?




LASER USE    yes   no

If yes, please fill out all of the fields in this section.

ANSI classification
Wavelength
Total Power
Laser hazard controls you will apply.

HAZARDOUS EQUIPMENT/ELECTRICAL EQUIPMENT?    yes No

If yes, describe any hazardous/electrical equipment you will be bringing to SSRL. Indicate if it is a commercial product and if it has been altered in any way.




2575 Sand Hill Road, MS: 99, Menlo Park, California, 94025, USA Tel: 650-926-4000 | Fax: 650-926-4100