Material Safety Data Sheet Sample Form

 

24-hour emergency- 777-2591        

 Submit Copy to the Safety and Environmental Health Office (BOX 9031, 777-3341)


Section 1.                PRODUCT AND COMPANY IDENTIFICATION

Product Name: _________________________________________________________________________________

Product Use: ____________________________________________________________________________________

Synonyms: _____________________________________________________________________________________

Other Designations: ______________________________________________________________________________


Section 2.                COMPONENT INFORMATION

This product is hazardous according OSHA 29 CFR 1910.1200.Hazards:

____Flammable/Combustible   ____Acute Toxin   ___Chronic Toxin   ___Carcinogen                                       

Pressure_____        Reactive_____        Exposure Limits___________ Target Organ(s)_________________________

Other__________________________________________________________________________________________


Section 3.                HAZARDS IDENTIFICATION

Ratings:

Health____ Flammability___ Reactivity___  Primary Route of Exposure:  _____Skin ___ Inhalation  ___Eye

Health Effect Information:

Eye Contact:__________________ Skin Contact:_________________ Inhalation:______________________________

Ingestion:_____________________ Medical Conditions Aggravated by Exposure: ______________________________

Section 4.   FIRST AID INFORMATION

Eye Contact: ____________________________________ Skin Contact:_____________________________________

Inhalation: ______________________________________ Ingestion:._______________________________________

Notes to Physician:_______________________________________________________________________________


Section 5.   FIRE AND EXPLOSION INFORMATION

Flammable Properties:_____________________________________________________________________________

Flash Point: _____  Test Method: __________________________________________

Flame extension: ____Test Method: __________________________________________

Flammable Limits in Air:    Upper Percent:_____    Lower Percent:_____

Autoignition Temperature :_____Test Method: __________________________________

NFPA Classification: (see NFPA 704 marking system):__________________________________________________

Extinguishing Media:  ____________________________________________________________________________

Fire Fighting Measures:

                Special Fire Fighting Procedures and Equipment: __________________________

                Unusual Fire and Explosion Conditions: _________________________________

                Hazardous Combustion By-Products: ___________________________________


Section 6.    ACCIDENTAL RELEASE MEASURES

Personnel Safeguards: ____________________ Regulatory Notifications: ____________________________________

Containment and Clean up: _________________________________________________________________________

_______________________________________________________________________________________________


Section 7.   HANDLING AND STORAGE INFORMATION

Handling: _____________________________Storage: ____________________________

Empty Container Warnings:

                Drums: ___________________________________________________________

                Plastic: ___________________________________________________________


Section 8.   EXPOSURE CONTROLS / PERSONAL PROTECTION INFORMATION

Exposure Limits and Guidelines:

Component

CAS No.

Exposure Limit

 

 

 

 

 

 

Personal Protective Equipment:

                Eye/Face Protection: ______________________________ Skin Protection:__________________________

                Respiratory Protection:____________________________ Personal Hygiene: _________________________

Engineering Controls / Work Practices

                Ventilation: _____________________________________________________________________________

Other: __________________________________________________________________________________
Section 9.                PHYSICAL AND CHEMICAL PROPERTIES

Appearance:

Vapor Pressure:

Odor:

 

Physical state:

Vapor Density (air=1):

pH:

Percent Volatile by Volume:

DOT Corrosivity:

Volatile Organic Content:

Boiling Point:

Molecular Weight:

Melting Point:

Average Carbon Number:

Specific Gravity:

Viscosity @ 100 F:

Pour Point:

Viscosity @ 40 C:

Solubility in Water:

 

Octanol / Water Coefficient: Log Kow =

 

 

Section 10.   STABILITY AND REACTIVITY INFORMATION

Chemical Stability:  ___________________________Conditions to Avoid:  __________________________________

Incompatible Materials to Avoid:  ____________________________________________________________________


Section 11.   TOXICOLOGICAL INFORMATION

Primary Eye Irritation:  _________________________ Primary Skin Irritation:  _______________________________

Acute Dermal Toxicity:  ________________________ Subacute Dermal Toxicity:_____________________________

Dermal Sensitization: __________________________ Inhalation Toxicity:  __________________________________

Inhalation Sensitization:  _______________________ Oral Toxicity:________________________________________

Mutagenicity:  _______________________________ Carcinogenicity:  _____________________________________

Reproductive Toxicity: ________________________ Teratogenicity: _______________________________________

Immunotoxicity: _____________________________ Neurotoxicity: ________________________________________

Other: ________________________________    or    _____No other toxicological information available


Section 12.   ECOLOGICAL  INFORMATION

Aquatic Toxicity: ____________________________ Terrestrial Toxicity: ____________________________________

Chemical Fate and Transport: _______________________________  or  _____No other ecological information available. 


Section 13.   DISPOSAL INFORMATION

Regulatory Information: ______________________ Waste Disposal Methods: ________________________________


Section 14.   TRANSPORTATION INFORMATION

U.S. Department of Transportation (DOT):_____________________________________________________________

Highway / Rail (Bulk): _____________________________________________________________________________

Highway / Rail (Non-Bulk): ________________________________________________________________________

The DOT description is provided to assist in the proper shipping classification of this product and may not be suitable for all shipping descriptions.

International Information:

Vessel: ____IMDG Regulated:               ____IMDG Not Regulated:   

Air:____ICAO Regulated:                      ____ICAO Not Regulated:    

Other information:_______________________________    or     ______No other information available. 


Section 15.   Regulatory Information

Regulatory Lists

U.S. TSCA Inventory:  All components of this material are on the US TSCA Inventory.

Sara Section 313: This product contains the following Sara, Title III, Section 313 Chemicals:

Chemical

CAS Number

Percent in Product

 

 

 

IARC Group 3:

Regulatory Lists Searched:________________________ Health & Safety: ___________________________________

Environmental:_________________________________ International:_______________________________________

State: _________________________________________ National Inventories: ________________________________

SARA 311 / 312 Categories

Acute:_____           Chronic:_____          Fire:_____  Pressure:_____  Reactive:____ Not Regulated:_____                     

Canadian WHMIS Classification:             Class:____  Division:_____

European Union Classification :               Hazard Symbol: _____         Risk Phrases: _____Safety Phrases:  _____

Other Regulations: ______________________________    or    ____No other information available. 

Section 16.   OTHER INFORMATION

Health and Environmental Label Language: _________________________MSDS Revisions:_____________________

Prepared By:  ________________________________________________________________________

Date:_________