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.

Notification: In accordance with the requirements of the University Chemical Hygiene Plan, this document serves as notification to the Office of Environmental Health and Radiation Safety of the use of the following class(es) of chemicals:

	Used	Not Used
Carcinogens or suspected
Acutely toxic chemicals
Acutely toxic gases
Reproductive hazards

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: _______________