Research Safety Questionnaire

RESEARCH SAFETY QUESTIONNAIRE
The purpose of this questionnaire is to assess the potential hazards for each laboratory at the MBL. The information obtained will be used by MBL safety personnel to: perform a risk assessment of the hazards and ensure compliance with applicable Federal, State and local regulations; and confirm if any protocol registration applications as required by the MBL’s institutional compliance committees (IBC, IACUC and Radiation Safety Committee) have been completed.

This form is to be completed annually. When any new hazards are introduced into the laboratory, the Principal Investigator/Course Director must resubmit this questionnaire with updated information.

Full Name
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Does the laboratory space contain hazards beyond those found in a common office space, such as: vertebrates, chemical hazards, biological hazards, radioactive or laser hazards, and/or physical hazards?
Please select one *
A “YES” response requires all hazard assessment sections of this questionnaire to be completed.
A“NO” response simply requires signing and dating the Questionnaire Attestation below.

Chemical Hazards

Does your laboratory use or store (check Yes or No for each)?

Acutely Toxic Chemicals (e.g. sodium azide, 2-mercaptoethanol, mercury)
Carcinogens, Teratogens and/or Mutagens (e.g. paraformaldehyde, chloroform, lead)
Corrosives (e.g. sulfuric, hydrochloric, perchloric, hydrofluoric acid, sodium hydroxide, ammonia)
DEA Controlled Substances (e.g. ketamine, pentobarbital)
Engineered Nanomaterials
Flammable Liquids (e.g. methanol, ethanol)
Gas Cylinders (e.g. hydrogen, methane, oxygen)
Oxidizers (e.g. chlorates, nitrates, peroxides, perchlorates)
Peroxide Forming Chemicals (e.g. diethyl ether)
Potential Explosives (e.g. picric acid)
Water-Reactive Chemicals (e.g. potassium, sodium, lithium)
Any Yes response requires submission of a Chemical Inventory before start of work.

Biological Hazards

Does your laboratory work with (check Yes or No for each)?

Human or non-human Primate-derived Materials (i.e. cells, blood, tissues, or organs (CBTO) harvested directly from humans or non-human primates)
Established and/or Immortalized Human/NHP Cell Lines (e.g. CACO-2, HeLa, HEK293)
Infectious Agents or Parasites (e.g. viruses, bacteria, fungi, protozoa, worms)
Infectious Proteins (e.g. prions, cell-penetrating peptides)
Non-Native Plants/Animals or Transgenic Plants/Animals
Recombinant or Synthetic DNA/RNA
Select Agents or Zoonotic Toxins (e.g. tetrodotoxin, conotoxin)
Vertebrate Animals (e.g. mammals, birds, fish, reptiles, amphibians)
Viral Vectors (e.g. adenovirus, adeno-assiciated virus, lentivirus)
Any Yes response (excluding Vertebrate Animals or Established Bloodlines) requires completion of an IBC application.
A Yes response for Human/NHP CBTO requires completion of an IRB application.
A Yes response for Vertebrate Animals requires completion of an IACUC application.

Radiation and Laser Hazards

Does your laboratory use (check Yes or No for each)?

Radioactive Isotopes (e.g. C14, P32, S35 isotopes)
Radioactive Materials (e.g. depleted uranium, uranyl or thorium-containing compounds)
Radioactive Sealed Sources (e.g. gas chromatographs with Electron Capture Detectors)
Class 3B or 4 Enclosed Lasers (including those used in optical microscopy)
Class 3B or 4 Open Laser Beams
Ultraviolet (UV) Light Sources
X-Ray Generating Devices (XRDs) (e.g. cabinet X-ray, XRF analyzer)
A Yes response for Radioactive Isotopes requires completion of an application to use Radioactive Materials.
A Yes response for Class 3B or 4 Laser (Open or Enclosed) requires an MBL Laser Registration form.

Physical Hazards

Does your laboratory use (check Yes or No column for each)?

Autoclave
Centrifuge
Cryogenic Liquids (e.g., liquid nitrogen)
Loud Equipment (e.g. sonicator)
Open Flames/High Temperature Equipment (e.g. Bunsen burner, hot plates)
Power Tools or Machine Shop Equipment (e.g. table saw, nail gun)
A Yes response may require Autoclave, Hearing Conservation or MBL Power Tool Training.

Personal Protective Equipment & Engineering Controls

Does your laboratory use (check Yes or No column for each)?

Chemical Fume Hood)
Biological Safety Cabinet
Eye Protection (e.g. safety glasses, goggles)
Protective Gloves (e.g. nitrile gloves, heat resistant gloves)
Sharp Containers
Biohazardous Disposal Bins
Broken Glass Containers

REQUIRED DOCUMENTS / REGISTRATION

Chemical Inventory submittal requirements, please see https://www.mbl.edu/services/safety/chemical-safety/
Institutional Biosafety Committee (IBC) form is available at https://www.mbl.edu/services/biosafety-committee/
Institutional Animal Care and Use Committee (IACUC) form is available at https://www.mbl.edu/services/iacuc/
Independent Review Board (IRB) protocol information at https://www.mbl.edu/osp/neirb/
Radioactive Material Use Application form is available at https://www.mbl.edu/services/safety/radiation-safety/
Laser Registration form is available at https://www.mbl.edu/services/safety/radiation-safety/

SAFETY TRAINING REQUIREMENTS

All Whitman Center and Advanced Training Course personnel are required to take the Chemical Safety Training annually (online or in person). As applicable, training is required for the followingControlled Substances Usage, Biosafety, Select Agent Usage, Radiation Safety, Laser Safety, Autoclave, Bloodborne Pathogens and Hearing Conservation. Please contact MBL Safety at safety@mbl.edu or 508-289-7424 for more information.

QUESTIONNAIRE ATTESTATION

MM/DD/YYYY