Carcinogen Use Notification

Name:
(Supervisor / Principal Investigator) ✻

Email:

(Supervisor/Principal Investigator) ✻

Department: ✻

Name of contact person:

(If different from Supervisor/Principal Investigator)

Email:

Phone Number:

What regulated carcinogens are you using? ✻

Non-listed carcinogens:

Where will you be using the carcinogens?
(check all that apply)

Building(s) & Room(s):

(If not reporting use N/A) ✻

Describe (briefly) each process or operation involving the carcinogen(s).

How many employees are estimated to be engaged in each process or operation?

Does anyone involved fall under
these collective bargaining unit groups?

Comments: