version 1.0: 11-8-2006
Application for Approval of Outreach Event
Department of Chemistry, Oregon State University
Instructions: Overtype the non-emphasized plain text within the table cells with your question responses. After signing the declaration at the end of form, and appending relevant material safety data sheets (MSDS), present the hard-copy application file to either co-chair of the current safety committee. The application will be reviewed by the committee and department chair and either approved or denied within three working days.
ONCE APPROVED, THE NATURE OF THE EVENT MAY NOT ALTER SIGNIFICANTLY FROM THAT DESCRIBED HEREIN WITHOUT FURTHER REVIEW.
1. Name: / Paul Dornath / 2. Date of event: / Week of 08/20/073. Contact information: , (503)-757-5295
4. Provide a brief description of proposed outreach event:
Working with K through 5th graders doing science experiments, hands on activities and demos. For the SKIES program
5. Where will event take place? and briefly describe nature of venue (capacity etc.):
Gleeson Hall at OSU. Room 200. There will be approximately 20 kids at a time and four to five supervising adults.
6. Describe make-up of intended audience/participants (number, age):
About 20 kids all performing a very controlled and supervised experiment. Ages 7 to 11.
7. How will the event be supervised? Comment on ratio of participants to supervisors and the selection of volunteer supervisors (e.g. faculty, graduate students, SAACS members):
There will be at most twenty kids, probably less, to four to five leaders. They will have the exact amounts of each substance already measured out, they will only have to mix in plastic bags.
8. What training/instruction will volunteer supervisors receive prior to event?:
They have been leading this camp all summer. I personally have been working with science demos and children for two years now.
9. List experiments/demonstrations to be performed:
1) The first will be an inflating bag reaction, where the kids will mix calcium chloride, baking soda and a phenol red indicator and watch it change color, heat up and inflate the bag.
2) The second will be the dynamic yellow to blue color change reaction that continually changes from yellow to blue and then back to yellow for a long period of time about twenty minutes). This requires potassium hydroxide, dextrose and methylene blue indicator. This will only be a demo, students will not touch this
10. List all chemicals (& quantities) to be used (including solvents, cryogens, and gases):
1) 10 grams phenolsulfonphthalein (for phenol red indicator)
2) 100 grams potassium hydroxide
3) 100 grams dextrose
4) 10 grams methylene blue indicator (solid)
[obtain MSDS for each substance and collate in appendix at end of application]
11. How will chemicals be transported to/from event and how will waste materials be managed?:
I can pick up the chemicals. We’ll put the POH-dextrose solution in a special waste container and we’ll though the other phenol red/calcium chloride baking soda waste away in our laboratory’s trash can.
12. What protective equipment will participants (& demonstrators) be provided with?:
Zip lock bags, 2 liter PET plastic bottles, scales, spoons, goggles, garbage bag ponchos.
13. What provisions have been made for the possibility of accidents (fire, chemical spills, injury/illness etc.)?
We have goggles, gloves, fire extinguishers, garbage bag ponchos, sponges and two exits to the room we’re in. We also have a first aid kit.
14. Declaration: I declare that the information provided above is accurate, that I have read and understood the implication of all relevant MSDS files, and that the nature of the event proposed will not alter significantly from that described.
Signed:...... Date:......
Approval by safety committee:
Event approved Event denied
Signed:...... Date:......
(chair)
Signed:...... Date:......
(safety committee representative)
List below dates and locations where this event has been repeated in essentially the same format:
DATE LOCATION COMMENTS
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