Instructions: Please complete this form, print, sign, and return it to the Office of Environmental Health and Radiation Safety.
3160 Chestnut Street, Suite 400, Philadelphia, PA 19104
For your convenience, this form is a also available in PDF Format.
Statement of compliance
I have reviewed the requirements of the University's Chemical Hygiene Plan and the applicable Standard Operating Procedures as they apply to carcinogens, acutely toxic chemicals, and reproductive hazards and have complied with all applicable requirements where appropriate.
Signature: ______________________________ Date: _______________