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Lab-Specific CHP Addendum Form

Lab-Specific CHP Addendum Form

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Laboratory-Specific CHP Addendum

Lab-Specific CHP Site Addendum Form

This form allows faculty and staff to apply for a Laboratory-Specific addendum to the Chemical Hygiene Plan.

When faculty or staff at Lindenwood University intend to handle Particularly Hazardous Substances (PHS) or other high-risk or regulated substances as described in the LU CHP, this form must be submitted for review by the campus Health & Safety Committee. PHS include, but are not limited to, reproductive toxins, carcinogens, and substances with a high acute toxicity (as per 29 CFR 1900.1450(e)(3)(vii)).

This form allows applicants to provide information and standard operating procedures specific to the laboratory or space in which the PHS will be handled. It is the responsibility of the applicant to provide an annual review of all laboratories and sites listed in this application.

Identification of Space Covered by this Laboratory-Specific Plan

Section Description

1. Name

First

Last

2. Email Address

3. Building

4. Room Number(s)

5. Principal Investigator or Lab Manager

6. Department Chair

7. Lab Safety Coordinator or Supervisor

Lab Emergency Contact Information

Section Description

8. School or Department Emergency Contact

9. Building Emergency Contact

10. Lab Emergency Contact

Lab Activity and Hazard Control Information

Section Description

11. Please describe the substance you will be procuring, and any specific hazards associated with the substance.

12. Briefly Describe all Laboratory Activities associated with the PHS

13. Summarize all hazard controls and hazard communication requirements required for use and handling of this substance.

14. Describe all PPE required in addition to PPE described for laboratory workers in the Chemical Hygiene Plan.

15. Describe any Special Emergency Procedures applicable to this substance.

16. Please upload any files or documents you think may be helpful for Health & Safety Committee review of this form.

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