SIF Materials & Experiment Safety Assessment (MESA)

SIF Materials & Experiment Safety Assessment (MESA)

USER INFORMATION

Last Name*

First Name*

Contact Email*

Contact Phone*

Work Address*

U.S. Citizen*

Yes

Ames Laboratory Employee Number*

*If associated with ISU, do not provide ISU University ID. Enter "ISU" instead.

Please provide the number on the back of your card*

Provide the 4 digit number on the back of your Ames Lab ID (bottom right).

If you do not have an Ames Lab ID, please provide the 6 digit number from the back of your ISU Card.

Once training is complete this allows for key access to be granted.

Organization Name*

Department*

Group Leader Name*

Group Leader Phone Number

Group Leader Email*

FUNDING

Funding Type*

Ames Laboratory

Iowa State University

Other

Project Funding Account/Worktag*

INSTRUMENTS

Check all requested instruments

NOTE: Training is required prior to independent use of each instrument

FEI Teneo LoVac (FE-SEM)

FEI Helios (FIB)

FEI Tecnai (TEM)

FEI Titan Themis (AC-TEM)

Usage

Experience*

Please note your experience, including dates and places, with any SEM/TEM instrumentation

Expected Frequency of Use*

Weekly

Monthly

Every 3 months

Every 6 months

Estimated number of samples*

for your chosen time frame

RESEARCH

Research*

Provide a detailed explanation of your research and sample preparation that you will conduct at the SIF

SAMPLES

All materials coming to the SIF must comply with DOT transportation regulations.

Common sample name*

Molecular Formula*

Approximate size and mass *per sample*

Report all quantities in grams; if liquid, report in milliliters. Please list g/ml in your answer. (eg, 5 ml or <1g)

*per sample = amount per vial/membrane box, ect

Number of samples*

# of vials/membrane boxes to be transported for this request

Known Hazards*

Check all that apply

Select

*If Nanomaterial, particle size*

*If Nanomaterial, is your sample bound or unbound?*

Bound Nanoparticle: An engineered particle “dispersed and fixed within a polymer matrix, incapable as a practical matter of becoming airborne” is BOUND. Unbound Nanoscale Particle (UNP): Not contained within a matrix under normal temperature and pressure conditions that would reasonably be expected to prevent the particles from being separately mobile. Examples of UNP include intentionally produced fullerenes, nanotubes, nanowires, nanoropes, nanoribbons, quantum dots, nanoscale metal oxides, nanoplates, nanolayers, and other engineered nanoscale particles.

Bound

Unbound

*If Nanomaterial and bound, describe how your material is bound?*

i.e. on a matrix/grid, in a solution, ect.

Is this material being transported in a solvent?*

Yes

SAFETY

Have any of your samples been irradiated with neutrons or ion beams?*

Yes

Will you be bringing human tissue, cell lines, or materials to the SIF?*

Yes

If yes, specify

Will you be bringing regulated foreign or domestic soil to the SIF?*

Yes

If yes, specify

Will you be performing any hydrofluoric acid or chemical etching at the SIF?*

Yes

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