Research Environmental Questionnaire

Research Environmental Questionnaire pdf format, Adobe Acrobat Required

  1. General Research Information

    Name of Principal Investigator:
    e-mail address:
    Name of Co-investigator:
    e-mail address:
    Lab Contact:
    e-mail address:
    Name of Research Project:
    University Unit (College):
    Date:

  2. General Usage Information

    Does this research involve the use of any of the following? (CHECK either "Yes" or "No"):
    (Provide as much detail as possible if YES):

    Yes   No     Human Blood, Body Fluids or Other Potentially infectious material?

    Detailed Information:

    Yes   No     Recombinant DNA, Infectious Agents or Biological Toxins?

    Detailed Information:

    Yes   No     Radioactive Materials and/or Ionizing or Nonionizing radiation Producing Equipment?

    Detailed Information:

    Yes   No     Animals?

    Detailed Information:

    Yes   No     Hazardous Chemicals?

    Detailed Information:

  3. Materials Used in Research

    If material is not used, please answer not applicable (N/A)

      How are these Stored? How are these packaged for removal? How are these disposed and by whom?
    Radioactive?
    Acidic or basic?
    (High or Low pH)
    Oxidizers?
    Heavy Metals?
    Biohazards (i.e. frozen tissue, etc.)?
    Solvents?
    Gases?
    Other (flammable, corrosive, reactive, explosive, toxic)

  4. Liquid Waste

    What liquid wastes (ex. chemicals, water, bleach) will be generated? How will you dispose of them (sink, removed by University Safety and Assurances (US&A) personnel)? Please explain each:

      Name Chemicals How Disposed
    Acidic or basic?
    (High or Low pH)
    Waste with trace amounts of metals?
    Salt solutions?
    Any other liquid waste materials not appropriate for sewer disposal (i.e., solvents, or concentrated solutions of formaldehyde, xylene)

    Yes   No     Will liquid residue (from DNA and/or RNA extractions), that will be treated as tissue culture waste and treated with bleach, be generated?

    If yes, how will it be removed?

    Yes   No     Will Ethidium Bromide (or other mutigen) be used in the research?

    If yes, please explain:

  5. Solid Waste

    What solid waste (needles, pipettes, agar plates--glass and/or plastic will be used or generated? Please list this waste.

    Solid Waste* How Disposed

    *Please be specific in your description of the waste and do not use generic phrases such as “plastic ware” or “glass ware”.

    Yes     No     Will solid waste be generated and removed as “normal trash”?

    Yes     No     Will any waste be autoclaved first?

    If yes, how will this autoclaved waste be disposed?

    Please state if any waste will be placed in special bags (red bags?) or containers (i.e., biohazard?) and will Safety personnel remove it?

    If animal carcasses are generated from the research, please explain the removal and disposal process.

    Yes     No     Will filters be used in RNA/DNA extractions?

    How will these be removed and disposed?

  6. Air Emissions

    Yes     No     Are there any air emissions or dust (particulates) that will result from this research?

    Yes     No     Is research conducted in a lab hood or exhausted from the lab in any way (i.e., fume hoods utilized)?

    Please be specific listing what emissions or particulates will result.

    Is any other equipment or process or chemical unique to the research being used that could result in air emissions?

 

Updated March 20, 2007 by SAK