[Department or laboratory name, building, room number(s)]
has certain procedures or activities that require prior approval from:
(name, title, campus address and campus telephone number)
before implementation. These procedures are as follows:
(List or insert specific procedures/circumstances that apply.)
There are special provisions for additional employee protection for work with particularly hazardous substances used. These substances include "select" carcinogens, reproductive toxins, and substances which have a high degree of acute toxicity.
Specific considerations for the particular hazardous substances are listed as follows:
(List or insert specific procedures for each particularly hazardous substances which could include establishment of a designated area, use of containment devices such as fume hoods or glove boxes, procedures for safe removal of contaminated wastes, and decontamination procedures.)