Research Safety Questionnaire

RESEARCH SAFETY QUESTIONNAIRE

If you are human, leave this field blank.

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.

Principal Investigator or Course Director: *

Full Name

Building (if known)

MBL Affiliation *

Room(s) (if known)

Course *

Department

Phone *

+1 ### ###-####

Email *

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 *

Does the laboratory space contain hazards?

YES

NO

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) *

Yes

No

Acutely Toxic Chemicals (e.g. sodium azide, 2-mercaptoethanol, mercury)

Carcinogens, Teratogens and/or Mutagens (e.g. paraformaldehyde, chloroform, lead) *

Yes

No

Carcinogens, Teratogens and/or Mutagens (e.g. paraformaldehyde, chloroform, lead)

Corrosives (e.g. sulfuric, hydrochloric, perchloric, hydrofluoric acid, sodium hydroxide, ammonia) *

Yes

No

Corrosives (e.g. sulfuric, hydrochloric, perchloric, hydrofluoric acid, sodium hydroxide, ammonia)

DEA Controlled Substances (e.g. ketamine, pentobarbital) *

Yes

No

DEA Controlled Substances (e.g. ketamine, pentobarbital)

Engineered Nanomaterials *

Yes

No

Engineered Nanomaterials

Flammable Liquids (e.g. methanol, ethanol) *

Yes

No

Flammable Liquids (e.g. methanol, ethanol)

Gas Cylinders (e.g. hydrogen, methane, oxygen) *

Yes

No

Gas Cylinders (e.g. hydrogen, methane, oxygen)

Oxidizers (e.g. chlorates, nitrates, peroxides, perchlorates) *

Yes

No

Oxidizers (e.g. chlorates, nitrates, peroxides, perchlorates)

Peroxide Forming Chemicals (e.g. diethyl ether) *

Yes

No

Peroxide Forming Chemicals (e.g. diethyl ether)

Potential Explosives (e.g. picric acid) *

Yes

No

Potential Explosives (e.g. picric acid)

Water-Reactive Chemicals (e.g. potassium, sodium, lithium) *

Yes

No

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) *

Yes

No

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) *

Yes

No

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) *

Yes

No

Infectious Agents or Parasites (e.g. viruses, bacteria, fungi, protozoa, worms)

Infectious Proteins (e.g. prions, cell-penetrating peptides) *

Yes

No

Infectious Proteins (e.g. prions, cell-penetrating peptides)

Non-Native Plants/Animals or Transgenic Plants/Animals *

Yes

No

Non-Native Plants/Animals or Transgenic Plants/Animals

Recombinant or Synthetic DNA/RNA *

Yes

No

Recombinant or Synthetic DNA/RNA

Select Agents or Zoonotic Toxins (e.g. tetrodotoxin, conotoxin) *

Yes

No

Select Agents or Zoonotic Toxins (e.g. tetrodotoxin, conotoxin)

Vertebrate Animals (e.g. mammals, birds, fish, reptiles, amphibians) *

Yes

No

Vertebrate Animals (e.g. mammals, birds, fish, reptiles, amphibians)

Viral Vectors (e.g. adenovirus, adeno-assiciated virus, lentivirus) *

Yes

No

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) *

Yes

No

Radioactive Isotopes (e.g. C14, P32, S35 isotopes)

Radioactive Materials (e.g. depleted uranium, uranyl or thorium-containing compounds) *

Yes

No

Radioactive Materials (e.g. depleted uranium, uranyl or thorium-containing compounds)

Radioactive Sealed Sources (e.g. gas chromatographs with Electron Capture Detectors) *

Yes

No

Radioactive Sealed Sources (e.g. gas chromatographs with Electron Capture Detectors)

Class 3B or 4 Enclosed Lasers (including those used in optical microscopy) *

Yes

No

Class 3B or 4 Enclosed Lasers (including those used in optical microscopy)

Class 3B or 4 Open Laser Beams *

Yes

No

Class 3B or 4 Open Laser Beams

Ultraviolet (UV) Light Sources *

Yes

No

Ultraviolet (UV) Light Sources

X-Ray Generating Devices (XRDs) (e.g. cabinet X-ray, XRF analyzer) *

Yes

No

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 *

Yes

No

Autoclave

Centrifuge *

Yes

No

Centrifuge

Cryogenic Liquids (e.g., liquid nitrogen) *

Yes

No

Cryogenic Liquids (e.g., liquid nitrogen)

Loud Equipment (e.g. sonicator) *

Yes

No

Loud Equipment (e.g. sonicator)

Open Flames/High Temperature Equipment (e.g. Bunsen burner, hot plates) *

Yes

No

Open Flames/High Temperature Equipment (e.g. Bunsen burner, hot plates)

Power Tools or Machine Shop Equipment (e.g. table saw, nail gun) *

Yes

No

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) *

Yes

No

Chemical Fume Hood)

Biological Safety Cabinet *

Yes

No

Biological Safety Cabinet

Eye Protection (e.g. safety glasses, goggles) *

Yes

No

Eye Protection (e.g. safety glasses, goggles)

Protective Gloves (e.g. nitrile gloves, heat resistant gloves) *

Yes

No

Protective Gloves (e.g. nitrile gloves, heat resistant gloves)

Sharp Containers

Yes

No

Sharp Containers

Biohazardous Disposal Bins *

Yes

No

Biohazardous Disposal Bins

Broken Glass Containers *

Yes

No

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

Attestation *

I certify that this questionnaire is accurate and complete. As applicable, I will complete any registration applications, ensure that all laboratory personnel receive required safety training, and ensure personnel use personal protective equipment that are needed for their assignment.

Signature *

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Date *
MM/DD/YYYY