EHS:

FACILITY PROJECT QUESTIONNAIRE

Principal Investigator/Customer:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Project Location Bldg./Room \_\_\_\_\_\_\_\_\_\_\_\_\_\_ FME Work Order
Number: \_\_\_\_\_\_\_\_\_\_\_\_\_

FME Project Manager: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1.  Will people occupy the space? Yes \_\_\_\_how many? \_\_\_\_
    No\_\_\_\_

2\. Will compressed gases be used in laboratory operations? Yes\_\_\_\_
No\_\_\_\_

> If yes, which gases?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Where will the cylinders be located
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Will flammable liquids be used in laboratory operations? Yes\_\_\_\_
No\_\_\_\_

If yes, \<60 gallons may be stored in flammable storage cabinet. \>60
gallons require flammable storage room.

> Flammable Cabinet \_\_\_\_\_\_\_\_ Flammable Room
> \_\_\_\_\_\_\_\_\_\_\_\_

4.  Will chemicals, reagents be stored in the space? Yes\_\_\_\_
    No\_\_\_\_

> a\) Shelf Yes \_\_\_\_ No \_\_\_\_
>
> b\) Corrosive Cabinet Yes \_\_\_\_ No \_\_\_\_
>
> c\) Oxidizer Cabinet Yes \_\_\_\_ No \_\_\_\_
>
> d\) Flammable Storage Cabinet Yes \_\_\_\_ No \_\_\_\_
>
> e\) Chemical Store Room Yes \_\_\_\_ No \_\_\_\_
>
> f\) Flammable Storage Room Yes \_\_\_\_ No \_\_\_\_

5.  Will other materials be stored in space? Yes\_\_\_\_ No\_\_\_\_

> a\) Shelving Yes \_\_\_\_ No \_\_\_\_
>
> b\) Dedicated storeroom Yes \_\_\_\_ No \_\_\_\_
>
> c\) Common area Yes \_\_\_\_ No \_\_\_\_

6.  Is any Biological Agent (human cell cultures, rDNA, RNA, etc) or
    biological toxin to be used in this laboratory?

> Yes \_\_\_\_ No \_\_\_\_ (If yes answer the following questions)

a)  Is agent or material a potential human or animal pathogen or toxin?

Yes\_\_\_\_ No \_\_\_\_

1.  If yes, does the work have a current Pathogen Registration (EHS
    Pathogen Registration \#
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

2.  If no, contact EHS for appropriate forms

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b)  Will the project include work with rDNA or rRNA?

Yes\_\_\_\_ No \_\_\_\_

1.  If yes, does the work have a current rDNA Registration (IBC rDNA
    Registration \# \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

2.  If no, contact EHS for appropriate forms

c\) If the biological agent is a potential pathogen what is the mode(s)
of transmission (aerosol route, direct contact, or
other)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

d)  Is antibiotic resistance expressed? Yes \_\_\_ No \_\_\_\_ other
    markers?\_\_\_\_\_\_\_

e)  Is a toxin produced? Yes \_\_ No \_\_ Will you work with the toxin?
    Yes \_\_\_ No \_\_\_ If yes, does toxin have an LD~50~ more than 100
    nanograms per kilogram body weight?

Yes \_\_\_\_ No \_\_\_\_

f)  Largest volume used is: \_\_\_\_ liters. Usual volume used is
    \_\_\_\_ liters.

g)  Will the work involve the use of human or animal tissues?

Please specify.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

h)  Will the organism be inactivated prior to disposal? Yes \_\_\_\_ No
    \_\_\_\_

Specify methods: Heat \_\_\_ Chemical \_\_\_ Radiation \_\_\_ Other
\_\_\_\_

i)  Do you anticipate the need for a dedicated autoclave? Yes\_\_\_ No
    \_\_\_

j)  Will you culture the organism? Yes \_\_\_ No \_\_\_

Specify amount \_\_\_\_\_\_

k)  Do you concentrate the organism? Yes \_\_\_ No \_\_\_

Specify methods: Centrifugation \_\_\_ Precipitation \_\_\_ Filtration
\_\_\_

Other \_\_\_\_

7.  What facility and practice biosafety level is necessary to perform
    the proposed work?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8.  Will animals be used in the proposed research? Yes \_\_\_\_ No
    \_\_\_\_

9\. Is there any possibility that you will generate chemical waste?

Yes­­­­­­ \_\_\_\_\_\_\_\_\_\_\_ No­­­­­­\_\_\_\_\_\_\_\_\_

> If yes, what is the largest quantity of waste that may be generated in
> one week:

a.  Flammable solvents: number of 5-gallon carboys\_\_\_\_\_\_\_\_\_\_\_
    number of 1-gallon carboys\_\_\_\_\_\_\_\_\_\_

b.  Chlorinated solvents: number of 5-gallon
    carboys\_\_\_\_\_\_\_\_\_\_\_ number of 1-gallon
    carboys\_\_\_\_\_\_\_\_\_\_

c.  Phenol/chloroform mixtures:

> Number of 1-gallon carboys\_\_\_\_\_\_\_\_\_\_

d.  Other chemical wastes \> 1 gallon per week: number of
    containers\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10\. Is there any possibility that you will generate medical waste?

Yes\_\_\_\_\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_\_

If yes, Medical waste: number of biomedical waste boxes \_\_\_\_\_\_

> number of tall trashcans \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11\. Do you plan to generate ordinary trash (paper, garbage, etc.)?

> Yes\_\_\_\_\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_\_

If yes, Ordinary trash: number of 30-gallon metal trash cans
\_\_\_\_\_\_\_

12\. Do you plan to generate recyclable materials (paper, aluminum,
glass, etc.)?

> Yes\_\_\_\_\_\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_\_

If yes, Recyclable: number of blue bins \_\_\_\_\_\_\_\_\_\_

13\. Will there be a dark room: Yes \_\_\_\_\_\_\_ No
\_\_\_\_\_\_\_\_\_\_\_

If yes, will the processing be automated \_\_\_\_\_\_\_\_\_\_ or manual
\_\_\_\_\_\_\_?

#  If automated, is there space for a silver recovery unit? Yes \_\_\_\_ No \_\_\_\_\_

14\. Will you need outdoor storage of supplies or equipment that could
release pollutants to storm water? Yes \_\_\_\_\_\_\_\_ No
\_\_\_\_\_\_\_\_\_

15\. Will you need emergency power? Yes \_\_\_\_\_\_ No
\_\_\_\_\_\_\_\_\_

16\. For new construction projects, has the DHHS Categorical Exclusion
Criteria Checklist been completed? Yes \_\_\_\_\_\_\_ No
\_\_\_\_\_\_\_\_ N/A \_\_\_\_\_\_\_\_

17\. For new construction projects, has the NIH Environmental Assessment
Criteria checklist been completed? Yes \_\_\_\_\_ No \_\_\_\_\_\_\_\_
N/A \_\_\_\_\_\_\_\_

18\. Will X-Ray Units be utilized? Yes\_\_\_\_\_ No\_\_\_\_\_\_

19\. Will Electron Microscope(s) be utilized? Yes\_\_\_\_\_\_
No\_\_\_\_\_\_

20\. Is there a possibility that you will use radioactive material?

#  Yes\_\_\_\_\_\_ No\_\_\_\_\_\_

21\. Is there a possibility of "human/medical use" involving radioactive
material?

#  Yes\_\_\_\_\_\_ No\_\_\_\_\_\_

22\. If you answered "yes" to questions 20 and/or 21 please complete the
following:

a)  Which isotopes will be utilized?
    List:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b)  List **mCi** amounts per experiment to be used **for each isotope**
    listed above.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

c)  List all radiological protocols (separate sheet may be utilized).

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

d\) List equipment containing "sealed sources" if applicable.

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

e\) Will iodinations be performed? Yes\_\_\_\_\_\_ No\_\_\_\_\_\_

23\. Is there any possibility that you will generate radioactive waste?
Yes\_\_\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_

> If yes, what is the largest quantity of waste that may be generated in
> one week:

a.  Dry radioactive waste: number of 30-gallon containers
    \_\_\_\_\_\_\_\_\_\_

b.  Liquid radioactive waste - half-life \< 15 days: number of 5-gallon
    carboys\_\_\_\_\_\_\_\_\_\_

c.  Liquid radioactive waste -- half-life 15-100 days: number of
    5-gallon carboys­­­­­­­\_\_\_\_\_\_\_

d.  Liquid radioactive waste -- half-life \> 100 days: number of
    5-gallon carboys\_\_\_\_\_\_\_\_\_

e.  Liquid scintillation vials: number of vial
    flats\_\_\_\_\_\_\_\_\_\_\_

24\. Is there any possibility that you will generate mixed waste
(regulated chemical waste that contains detectable radioactivity)? Yes
\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_

> If yes, mixed waste: number of 1-gallon carboys \_\_\_\_\_\_\_\_\_\_\_

25\. Are there any security concerns for your department?
Yes\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_

(i.e., access restrictions, specific instructions for security staff
making rounds).

If yes, please specify
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

26\. Will liquid nitrogen or other cryogenic liquids be used in the
space? Yes \_\_\_\_\_\_ No \_\_\_\_\_

If yes, please list
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Will the cryogen be supplied in portable dewars delivered to the space
> or plumbed into the space from a bulk tank? Other delivery system?
> Explain\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_