University of ColoradoHealthSciencesCenter
Animal Care & Use Program
Hazardous Material Information Questionnaire
Note: Standard Operating Procedures (SOP) will be prepared for use of this hazardous material, based upon this questionnaire. Please be complete and accurate.
Principal Investigator & Phone Number / Protocol Number
Species to be used / Name of Substance
Amount Per Animal / Dates of Usages (from / to):
Route of Administration / Length of Hazardous Period
Route of Excretion

Hazard Class of Substance …. (check box)

Attach a copy of material safety data sheet (MSDS) to the questionnaire if the substance is not found on list of “hazardous drugs” attached to this section.
___Moderately Toxic Chemical (no special hazards) ...... vitamins, aspirin, etc.
___Highly Toxic Chemical (LD 50 < 50 mg/kg) ...... sodium cyanide, strychnine
___ Toxins ...... aflatoxin, pricro toxin, cholera toxin, snake, etc.
___ Experimental or Investigational Drugs ...... ( hazardous mechanism of action)
___ DEA Controlled Substances ......
___ Hazardous Drugs . . . .
___ Carcinogen...... antineoplastic drugs, methyl methanesulfonate
___ Mutagen ...... ethidum bromide, penazine methosulfate
___ Teratogen ...... lead, bromodeoxyuridine
___ Reproductive Toxicity at low doses ( 1 mg/kg/day) ...... (handle as hazardous drug)
___ Organ Toxicity at low doses (1 mg/kg/day) ...... (handle as hazardous drug)
___Radioactive Materials ...... carbon14, tritium, I131
___ Human infectious agents......
___Animal infectious agents ......
___Select Agents ......
Potential for Disease in Humans (include NIH Risk Group category if known)
Potential for Disease in Animals
Personnel Protective Equipment Required (check all that apply)
___Gloves (latex, nitrile, neoprene, rubber, PVC) ___ Dust Mask ___Shoe Covers ___Scrubs ___Gowns
____Head Cover ___Respirator (HEPA, chemical, other) ___Face Shield ___Eye Protection
___ Other (Specify):
Radioactive Materials For radioactive materials follow the procedure below:
Containment Procedures For hazardous drugs, experimental drugs, select agents or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Containment Procedures Guidance:
Bedding Change Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Bedding Change Guidance:

Cage Cleaning Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:

Additional Cage Cleaning Guidance:
Waste Handling Procedures For hazardous drugs, experimental drugs, substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Waste Handling Guidance:
Carcass Disposal Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Carcass Disposal Guidance:
Personnel Exposure Emergency Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Personnel Emergency Guidance:
Spill Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Spill Procedure Guidance:
Personnel Exposure Monitoring Procedures For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Additional Personnel Exposure Monitoring Guidance:
Other Protection, Monitoring, or Control Procedures not Included Above For hazardous drugs, experimental drugs, or substances which are: carcinogens, mutagens, teratogens, reproductive or organ toxicity at low doses, follow the procedure below:
Other Contact Personnel (Include telephone numbers)

RETURN COMPLETED FORM TO: IACUC Office

/ Questions? Call 303.724.1056

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