Hazardous Substance Use Record Form
Please complete this form to accurately record each hazardous substance use event. All information helps ensure safety and compliance.
Person or Department Responsible
*
Substance Name or Identification
*
Date and Time of Use
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Quantity Used (specify units)
*
Purpose of Use
*
Please Select
Research
Manufacturing
Cleaning
Maintenance
Disposal
Other
Location of Use
*
Storage or Handling Method
*
Please Select
Standard Storage Cabinet
Ventilated Storage
Refrigerated Storage
Temporary Holding Area
Other
PPE or Safety Controls Used
*
Gloves
Lab Coat/Apron
Goggles/Face Shield
Respirator
Fume Hood
None
Other
Were there any incidents, spills, or exposures?
*
No
Yes (please describe below)
Additional Notes or Incident Description
Submit Record
Should be Empty: