Experimental Review and Process Safety Form

Personal Information

Experiment Information

Experiment Run Time
ContinuousLimited Time

Design Specifications:

Emergency Shutdown Procedure:

Chemical Hazards

Select Chemical Hazards:
FlammableToxicReactivePyrophoric or Water-ReactiveEnvironmental hazardCorrosiveIrritant

Potential Routes of Exposure:

Engineering Controls:
Chemical fume hoodSnorkelGloveboxOther

Special Handling, Transferring, and Storage Requirements:

Physical Hazards

Select Physical Hazards:
ElectricalNoise (please specify source below)Gas cylindersTemperature (please specify below)PressureVacuumGas flow (please specify pressure below)Vibration (please specify source below)Machine/moving parts (please specify below)High voltageExposed wiringHigh currentHome-built electrical components

System Design:
Open systemClosed system
If closed, is there a pressure relief valve?

Personal Protective Equipment

Protective Clothing:
Lab coat (please specify type below)Chemical-resistant apronArm sleeves

Eye and Face Protection:
Safety gogglesSafety glassesFace shield

Hand Protection:
Disposable gloves (please specify type below)Reusable gloves (please specify type below)Work glovesCryo glovesCut-resistant gloves

Hearing Protection:
Ear plugsEar muffsEnrolled in the EHS Hearing Conservation Program

Respiratory Protection:
Air-purifying respirator (please specify type below)Atmosphere-supplying respirator (please specify type below)Enrolled in the EHS Respiratory Protection Program

Head Protection:
Hard hat type IHard hat type IIBump cap

Protective Footwear:
Metatarsal guardsToe guardsSafety shoesElectrically conductive shoesNon-conductive shoes

Chemical, Biological, Radiological Waste Disposal Practices:

Safety Resources: