Two Major Events to Celebrate in 2015

In order to assure that potentially hazardous substances being submitted to McCrone Associates, Inc. (MA) for analysis are handled, stored, and disposed of safely and properly, we request that you complete and submit this form to MA for evaluation and approval prior to submitting samples for analysis. This form does not supersede or replace the need for a client to submit a Safety Data Sheet (SDS) when available and/or sample submission form, but rather is intended to be used as a pre-receipt hazard assessment tool by McCrone Project Leaders to complement the SDS or provide information where no SDS is available. Controls and procedures recommended should be consistent with those for handling the material in your workplace. Please seek assistance from your company's Environmental, Health and Safety Department, as necessary. Receipt of this form by MA does not constitute an acceptance of the sample for analysis. MA cannot receive materials that require a RAM license, contain actinides, and/or exhibit current or past radioactivity.

Client Contact Information

Company Name (required)

Contact Name (required)

Your Email (required)

Sample Hazard Warning, Toxicity Information, and Exposure Control

Product Name/Description:

UN ID:

No. of Units:

Unit Volume/Mass:

Concentration of API:

Physical State/Form:
LiquidPowderSolidTableGelOintmentOther
If Other:

Container Type:
VialSyringeIV UnitOther
If Other:

Known or Probable Health Hazards:
CarcinogenTeratogenMutagenAcutely ToxicFlammableCorrosiveIrritantBiohazard (select BSL# below)PathogenNoneUnknownOther
If Biohazard, select the BSL#:
---123
If Other:

If a Biohazard, Type:
Human Cell LineMonoclonal AntibodyBlood or OPIMExplant Medical DeviceHormoneProteinHuman siRNAVirus/Viral VectorBacteriaFungiOther
If Other:

Virus/Viral Vector:
LiveDeactivated

Replicant:

CompetentIncompetent

Recombinant:

YesNo

OEL/PEL (µg/m³):

Oral LD₅₀ (mg/kg):

Inhalation LD₅₀ (mg/kg):

Dermal LD₅₀ (mg/kg):

NOAEL (mg/kg/day):

Safe Handling Environment/Engineering Controls:
Open BenchLaminar Flow HoodChemical Fume HoodBiosafety Cabinet (select type below)GloveboxNoneUnknownOther
If Biosafety Cabinet was checked, select type:
---A1A2B1B2C1
If Other:

Personnel Protective Equipment (PPE):
Protective GarmentLaboratory Gloves (select type below)Protective EyewearRespirator (specify type below)NoneUnknownOther
Type of Laboratory Gloves, if checked above:
---Double GloveLatexNeopreneNitrile
Type of Respirator, if checked above:

If Other:

Spill Contaminant/Disinfection:

Additional Comments:

By submitting this form, in lieu of a signature, I am confirming that, to the best of my knowledge, all of the information included, herein, is current, accurate, and true as it pertains to sample materials to be submitted to MA.