Request for Chemical Purchase
Hazard Communication Program v3 Page | 1
Santa Clara University ©2016
Today’s Date (MM/DD/YYYY): _______________
To request a chemical product evaluation by EHS:
1. Requestor shall complete sections 1, 2, 3 and 4 of this form.
2. Attach a copy of the Material Safety Data Sheet (MSDS) or Safety Data Sheet (SDS) from the Manufacturer.
3. Requestor will be notified from the EHS Director or Safety Manager advising them of the status of the Chemical
Product Evaluation.
Section 1: REQUESTER INFORMATION
Employee Name (First Name, Last Name): _________________________________________________________
Department: ☐ Building Maintenance ☐ Custodial Services ☐ Grounds Maintenance ☐ Utilities
☐ Other
Section 2: PRODUCT INFORMATION
Product Name: _______________________________________________________________________________
Manufacturer Name: __________________________________________________________________________
Section 3: USAGE INFORMATION
Typical Container Size: ____________☐ Gallons ☐ Ounces ☐ Pounds ☐ Other: ___________
Container Type: ☐ Drum ☐ Glass Bottle ☐ Plastic Bottle ☐ Other: _________________________
Storage location: ______________________________________________________________________
Total volume to be kept in-stock: ________________________________________________________________
Section 4: INTENDED LOCATION FOR USE AND HOW IT WILL BE USED
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Section 5: ☐EHS Director or ☐EHS Manager Signature: _________________________________________
☐ Approved for Use (See Note Below) ☐ Denied for Use (See Note Below) ☐ Restrictions (See Note Below)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Section 6: PPE REQUIRED:
☐ Acid Gloves ☐ Ear Plugs ☐ Latex Gloves ☐ Nitrile Gloves
☐ Respirator ☐Face Shield ☐ Safety Glasses ☐ Safety Goggles
☐ Other: __________________
