750 Main_Chemical Hazard Amendment Form

Chemical Hazard Amendment Form
Please complete all applicable sections of this form. Any sections that do not apply to the nature of your work can be left blank.

The purpose of this Amendment is to inform The Engine Environmental Health and Safety (EHS) team of additional chemical hazards you will be working with, and the risks that they may present to you and those around you. All information must be comprehensive, true, and must be to the best of your knowledge.
Chemical Hazard Amendment

The Chemistry laboratories are located on Floor 2 at The Engine. These include chemical fume hoods, snorkel exhaust, vented waste cabinets, and chemical storage.
Chemical Hygiene Officer (if different than on file)
Chemical Hygiene Officer Email (if different than on file)
example@example.com
Chemical Hygiene Telephone (if different than on file)

Please note which types of hazardous. materials you will be adding

	Yes	Quantity >4L?	Please Describe
Flammable Liquids, solids, or gasses
Corrosive Liquids (acids or bases)
Compressed Gasses
Highly reactive materials
Explosives
Oxidizers
Highly Toxic Materials
Perchloric Acid
Hydrofluoric Acid
Diethyl Ether, Tetrahydrofuran, 1,4 Dioxane, Isopropyl Ether
Cyanides and Cyanates
Solder (lead or lead-free)

Please provide a description of the new workflow:
Will you be adding any DEA Schedule I-V Controlled Substances or any MDPH Schedule VI Controlled Substances? If so, please list them here and describe the application.
Please refer to the DEA List of Controlled Substance for the current list of controlled substances. Massachusetts Department of Public Health schedule VI substances are all prescription drugs not on the DEA schedules I-V.
Will any chemical reactions occur in vessels > 2.5G (10L)? If yes, please describe
Please provide a complete chemical inventory of all chemicals and reagents that you anticipate working with in the labs. *

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Please note, upon moving in, you will be required to complete and maintain your chemical inventory through our online software, SciShield.
Laboratory Chemical Waste Generation
Do you anticipate generating any waste water or any material outside of soap and water that will be discharged into sinks? *
Please note that The Engine holds a Category II Waste Water Permit through MWRA. Hazardous Materials in any concentration are not permitted to be discharged down laboratory sinks, and must be collected as waste.
Please describe the anticipated volume and profiles of the new waste stream that you anticipate generating in the laboratory per week.

Certification and Signature
Certification and Signature

I agree to abide by the following requirements:
- I will ensure that shop/laboratory personnel have received appropriate information about the shop, physical, chemical, laser, and/or biological hazards of the research outlined in this assessment by making available information regarding precautions to be taken to prevent exposures or release to the laboratory or the environment.
- I am familiar with and will ensure use of appropriate shop and/or laboratory practices and procedures in the conduct of this research.
- I certify that shop and/or laboratory personnel have appropriate technical expertise. I will ensure that shop and/or laboratory personnel know the procedures for dealing with incidents and spills of chemical materials and know the appropriate waste management procedures.
- I will ensure that all shop and/or laboratory personnel have completed all necessary training and that their training records are up to date. If this research changes to involve the use of any organism, microorganism, cell line, viral vector, or any other biological agent that is not explicitly listed above,
- I will submit information pertaining to those new agents to The Engine Accelerator for approval. If this research changes and requires the use or any recombinant DNA technology or other genetic manipulation not explicitly listed above.
- I will submit information pertaining to those new agents to The Engine Accelerator for review.
- If any new project is to be undertaken that is not explicitly listed above, I will submit an additional Safety Assessment Form to The Engine Accelerator EHS team.
- I understand that acceptance of this Assessment Form, as written, does not constitute a requirement for The Engine Accelerator to accept or approve any additional work at any Engine operated facilities.
- I understand that The Engine Institutional Biosafety Committee is required to review each Biological Project Assessment Form and any applicable
As the Principal Investigator, and on behalf of blanks* , I certify that the provided information is accurate and complete.
Principal Investigator Signature*

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Date*

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The Engine Environmental Health and Safety Representative

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Date

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