Appendix B

Use of Hazardous Agents in Animals

Supplemental Safety Operating Procedures Form

I. Project Information
Principal Investigator	Phone Number	e-mail	ACUC Protocol Number
Protocol Title
II. Hazardous Agents or Procedure Information
List hazardous agent(s):
Potential hazard to personnel	Reproductive hazard	Toxic	Carcinogen	Disrupts or alters biological process	Other
Potential routes of exposure	Inhalation	Dermal	Ingestion	Injection	Other
Potential amount of agent that may have a biological effect in animal care personnel or laboratory personnel.
Yes	No	Specific groups (e.g. pregnant women, immune-compromised), are restricted from contact with hazardous agents or procedures or with animals under treatment with hazardous agents?
If yes, identify group.
Yes	No	References or support document regarding chemical or drug toxicity effects are provided.
Yes	No	Additionally, SDS readily available for cleanup and emergency guidance?
Yes	No	Work would require special procedures or precautions during animal treatment, administration, or care? (if yes, complete Section IV)
Yes	No	Work would require special laboratory procedures or precautions during hazardous material handling or preparation? (if yes, complete Section V)
Yes	No	Work would require biosafety cabinet, fume hood or other safety device during animal treatment, administration, or care? (if yes, complete Section IV and V)
Yes	No	Are hazardous agents excreted or shed into animal bedding or exhaled?
If yes, describe expected shedding or excretion amounts and rate.
NOTE: Outside room entry door will be posted for hazardous agent use and the inside of the door will be posted with this Appendix B.
III. Treatment Information
Species	Agent	Administration route (injection, water, etc.)	Site	Volume and concentration	Number of Doses	Interval Between Doses	Total time of treatment of all groups
NOTE: All Cage or housing must identify hazardous agents (e.g. BrdU) and date of treatment.
Yes	No	Require special cage or housing (e.g. filter top cage)?
If yes, describe cage or housing requirement.
Yes	No	Bedding can be disposed by established LAR procedures?
If no, describe additional precautions for bedding disposal:
Yes	No	Carcass can be disposed by established LAR procedures?
If no, describe additional precautions for carcass disposal:
Yes	No	Routine LAR decontamination procedures are acceptable?
If no, describe additional precautions for decontamination procedures:

IV. Precaution(s) for Animal Care Personnel
Potential risk to animal care personnel:
Personal Protective Equipment:
Yes	No	Personal protective equipment is need ABOVE the standard measures (e.g. laboratory coat/scrubs, gloves) for working with animals? If yes indicate below.
Safety Glasses	Face Shield	Specific Laboratory Coat:
Chemical Splash Goggles	Apron	Specific Gloves (type):
Dust Mask	Other. Please describe:	Respirator (type):
(Respirators require EH&S approval)
Additional engineering controls (Biosafety cabinet, fume hood or other safety device exhaust/barrier):
Specific animal husbandry instructions or precautions:
Specific work practices (i.e. Must not work alone):
V. Precaution(s) for Laboratory Personnel
Potential risk to laboratory personnel:
Personal Protective Equipment:
Yes	No	Personal protective equipment is need ABOVE the standard measures (e.g. laboratory coat, gloves) for working with animals and/or hazardous agents? If yes indicate below.
Safety Glasses	Face Shield	Specific Laboratory Coat:
Chemical Splash Goggles	Apron	Specific Gloves (type):
Dust Mask	Other. Please describe:	Respirator (type):
(Respirators require EH&S approval)
Additional engineering controls (Biosafety cabinet, fume hood or other safety device exhaust/barrier):
Specific instructions or precautions when handling hazardous agents or procedures:
Specific work practices (i.e. Must not work alone):

VI. Emergency Procedures
Yes	No	References or support document or SDS available for emergency guidance?
If yes, list location.
FOR WOUNDS OR NEEDLESTICKS
For severe injuries – go immediately to the hospital and contact your supervisor later for instructions For non-emergency injuries: Wash area thoroughly with soap and water, rinse/flush for 15 minutes. Notify your supervisor or other designated employee If non-emergency medical care is needed, call AmeriSys to file a claim 1-800-455-2079 and follow their instructions about where to seek medical attention Take copy of the MSDS with you. For injuries that occur after hours - go to the hospital for emergencies or seek medical follow up the next day for non-emergency care following the steps above
FOR SKIN, EYE OR MUCOUS MEMBRANE EXPOSURES
For skin exposure, flush immediately at nearest sink for 15 minutes. Be careful not to bruise or break skin surface. For eye exposure, flush immediately at nearest eyewash station for 15 minutes. IF wearing contacts, remove before flushing eye. Notify your supervisor or other designated employee If non-emergency medical care is needed, call AmeriSys to file a claim 1-800-455-2079 and follow their instructions about where to seek medical attention Take copy of the MSDS with you. For injuries that occur after hours - go to the hospital for emergencies or seek medical follow up the next day for non-emergency care following the steps above COMPLETE AN INJURY REPORT: http://www.safety.fsu.edu/forms/injury.pdf Submit form to: FSU Environmental Health and Safety Milton Carothers Hall Room 1200 MC 4481 Or call: 644-6895 for information and guidance
VII. Statement of Responsibility
As Principal Investigator for this proposal, I have the responsibility to assure that my laboratory is operated in a safe manner and that all staff and students are informed of potential risk(s), wear appropriate personal protective equipment, and are adequately trained. I will assure that all students and staff working in my laboratory receive orientation to laboratory safety instructions, MSDS files and laboratory Emergency instructions. I understand that I am responsible for assuring that my laboratory is in compliance with all federal, state, and local environmental laws and regulations. Additionally, I am responsible for adhering to FSU EH&S policies and procedures for handling hazardous materials and for addressing accidental spills and personnel contamination. I will report any significant problems and/or significant research-related accidents and illnesses to Environmental Health and Safety, and will complete required forms in the event of an incident or injury. I further understand I must complete a new Supplemental Safety Operating Procedures Form and obtain approval prior to instituting any changes in my animal research.
Principal Investigator Signature	Principal Investigator (please print)	Date
VIII. EH&S USE ONLY
Room(s) or Approved Facility:
EH&S Initial	ABSL-2	Chemical
Date:	Radioactivity	Other Hazard

The expiration date of this Form is concurrent with the IACUC protocol