ERPG Value Candidate Agent Nomination Request Form

ERPG Value Candidate Agent Nomination Request Form

NOTE: The ERP Committee’s role is to review existing toxicological research available in the public domain or produced by a corporation or other third party. The committee does not fund primary research.

If you have any questions, please contact Michele Twilley.

Requestor Information

First Name

Last Name

Nominating on Behalf Of:

List employer or client if applicable.

Country

Select or enter value

Phone

Email

AIHA Member?

Yes

No

Candidate Agent

Name of Candidate Agent

CAS Number

Synonyms/Trade Names

Is it a high production volume chemical?

Yes

No

Amount Transported Annually in Commerce

[ ] LBS [ ] KG [ ] TONS

Is there a potential for agent to be released and generate significant exposures to workers, emergency response personnel, the environment or community?

Yes

No

Provide Additional Information

Is there a potential for significant adverse health effects from inhalation or dermal exposure?

Yes

No

Provide Additional Information

Chemical or Biological Warfare Concern

Yes

No

Provide Additional Information

Availability of Regulatory or Guide Value by Credible Organization

Yes

No

Provide Additional Information

Comments

Please provide any additional comments in the text box below.

Send me a copy of my responses

Powered by

Privacy Notice|Report Abuse