University of Kentucky CHEMICAL HYGIENE PLAN For ___________________________________ Principal Investigator/Laboratory Supervisor (Chemical Hygiene Officer) ____________________________________ Department ____________________________________ Room and Building
_____________________ Campus Phone	_______________________ After-hours Emergencies
Location of laboratories (specify all rooms in which hazardous materials are stored). ______________________________________________________________________________ ______________________________________________________________________________ Authorized Personnel Laboratory personnel: List all employees and students that use hazardous materials under your jurisdiction. Also indicate laboratory supervisor, if applicable, and his/her after-hours emergency telephone number.

Name**
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Status (e.g. research asst., student)
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

_________________________________________________
Signature of Principal Investigator/Laboratory Supervisor
(Chemical Hygiene Officer)

_________________________
Date
_________________________
Annual Revision Date
_________________________
Annual Revision Date
_________________________
Annual Revision Date
_________________________
Annual Revision Date

NOTE:    Maintain the original copy of this form in Laboratory Chemical Hygiene Plan binder. Submit
              photocopy or e-mail to:
                            Lab Safety Specialist
                            UK Occupational Health and Safety Dept.
                            252 East Maxwell St.
                            CAMPUS 0314


** Attach additional pages, if necessary.

Name** _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________	Status (e.g. research asst., student) _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________
_________________________________________________ Signature of Principal Investigator/Laboratory Supervisor (Chemical Hygiene Officer)	_________________________ Date _________________________ Annual Revision Date _________________________ Annual Revision Date _________________________ Annual Revision Date _________________________ Annual Revision Date

NOTE: Maintain the original copy of this form in Laboratory Chemical Hygiene Plan binder. Submit photocopy or e-mail to: Lab Safety Specialist UK Occupational Health and Safety Dept. 252 East Maxwell St. CAMPUS 0314 ** Attach additional pages, if necessary.