Addendum B

Pre-Approval Form for Requisitions with Hazardous Items or Vehicles

Requester’s Name: ______and email

Note: Requester must be Principle Investigator or faculty member for teaching laboratories in cases of purchases requiring approval of Environmental Health and Safety.

Requester’s Signature: ______Date: ______

Requisition Number (attach requisition paperwork): ______

Department Contact for Requisition: ______and email ______

Itemization of materials to be purchased (attach additional documentation if needed):

______

______

______

______

______

Approvals, as appropriate (Requestor must check applicable category below.):

Department of Environmental Health and Safety: email to

___ Radioactive Materials Date: ______

___ X-Ray Machines______Date: ______

___ Class 3b and 4 lasers______Date: ______

___ Biological Agents that are either Select Agents/Toxins

or Risk Groups 2 or 3 ______Date: ______

___ Biological Safety Cabinets ______Date: ______

___ UH Controlled Chemicals (see list below) ______Date: ______

Peroxide Forming Chemicals/ Chemicals requiring special handling / Acutely Toxic Chemicals / Toxic Compressed Gases / Shock Sensitive Compounds
Chlorobutadiene / Acrolein / Arsenic pentafluoride / Alkyl nitrates
Chlorotrifluoroethylene / Acrylyl chloride / Arsine / Alkyl perchlorates
Methyl methacrylate / Chlorine dioxide / Bromine pentafluoride / Diazo compounds
Tetrafluoroethylene / Chlorine trifluoride / Carbonyl fluoride / Dry diazonium salts
Vinyl acetylene / Chloropicrin / Carbonyl sulfide / Metallic azides
Vinyl chloride / Cyanogen chloride / Chlorine dioxide / Nitrocellulose
Vinyl pyridine / Cyanuric fluoride / Chlorine pentafluoride / Picric acid, dry
Vinylidene chloride / Decaborane / Chlorine trifluoride
Acetal / Dichloro acetylene / Cyanogens
+Diacetylene / Dimethylsulfide / Cyanogen chloride
Divinyl acetylene / Ethylene chlorohydrin / Diborane / Highly Hazardous Chemicals
Methyl acetylene / Ethylene fluorohydrin / Dinitrogen tetroxide / Aconitine
Methyl cyclopentane / Hexamethylene diisocyante / Fluorine / Bis (chloromethyl) ether (dichloromethyl)
Methyl-i-butyl ketone / Hexamethyl phosphoramide / Germane (GeH4) / Amanitin
Tetrahydronaphthalene / Iron pentacarbonyl / Germanium tetrafluride / Diisopropyl Fluorophospate
Vinyl ethers / Isopropyl formate / Hydrogen cyanide / Chloromethyl ether methyl
Hydrofluoric acid / Methylacryloxyethyl isocyante / Hydrogen fluoride / Microcystin
Methylene biphenol isocyante / Hydrogen selenide / Soman
Methyl fluoroacetate / Hydrogen sulfide / Tabun
Any Chemical Purchased in Quantities in Excess of 40 Gallons / Methyl fluorosulfate / Methyl bromide
Nitrogen tetroxide / Methyl mercaptan
Oxygen difluoride / Monomethylamine / Chemicals Containing Radioactive Materials
Pentaborane / Nitrogen dioxide / Uranium
Perchloromethyl mercaptan / Phosgene / Thorium
Phosphorus trichloride / Phosphine
Sarin / Phosphorus hexafluoride
Sulfur monochloride / Selenium hexafluoride
Sulfur pentafluoride / Silicon tetrafluoride
Sulfuryl chloride / Stibene (SbH3)
Tellurium hexafluoride / Sulfur tetrafluoride
Tetramethyl succinonitrile / Sulfuryl fluoride
Tetranitromethane / Tungsten hexafluoride
Toluene-2,4-diisocyanate / Vinyl chloride
Trichloro (chlormethyl) silane

Department of Facilities Management: email to

___ Vehicles (MAPP 03.01.04) Date: ______

Routing Instructions for Addendum B

1. The completed Addendum B, purchase requisition, and related paperwork (vendor quote, etc.) must be scanned and emailed to for Environmental Health & Safety approval or to for Facilities Management approval.

2. Once the Addendum B is approved (signed) by Environmental Health and Safety or Facilities Management, the Addendum B will be scanned and emailed to the Requestor and the Department Contact noted above.

3. The Department Contact will attach the approved Addendum B to the requisition in the Finance System and send it to Purchasing through electronic workflow.

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