Form NIH 2936 Application for Special Exception for Procurement and Use of Mercury

Form NIH2936 or the "Application For Special Exception For Procurement And Use Of Mercury" is a form issued by the U.S. Department of Health and Human Services - National Institutes of Health.

The form was last revised in October 1, 2012 and is available for digital filing. Download an up-to-date Form NIH2936 in PDF-format down below or look it up on the U.S. Department of Health and Human Services - National Institutes of Health Forms website.

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NIH ORF Division of Environmental Protection
Application for Special Exception for Procurement and Use of Mercury
(Use prescribed by NIH Manual 3033)
In accordance with Manual Issuance 3033 NIH authorizes limited exceptions for certain scientific and medical uses of
mercury and its compounds for which there are no acceptable alternatives. Examples of such uses may include, but
are not limited to, calibration of measurement instruments; fixatives used in histology; components of existing
equipment that cannot be replaced; research on mercury toxicology; and property that contains mercury as a
necessary component.
APPLICATION PROCESS:
1. Applicant seeking to procure or use mercury added products or mercury containing devices with a total mercury
concentration equal to or greater than 100 parts per billion shall submit a written application for a Special
Exception to the Division of Environmental Protection (DEP), ORFDO.
2. Applicants are required to have the application for the exception reviewed and signed by their Institute or Center
(IC) Scientific Director before submission of the application to the DEP Director.
REVIEW and APPROVAL:
1. The DEP Director or designee shall notify the applicant and IC Scientific Director within three business days of
an approved Special Exception request.
2. If the application is not approve, the DEP Director or designee shall return it to the applicant within ten business
days with an explanation stating why it was not approved and a recommended course of action. The IC
Scientific Director shall be copied on this notification.
3. An approve application is valid for five years.
Special Exception Procurement:
1. The applicant shall provide a copy of the approved special exception application to his or her procurement
official to authorize the procurement of the mercury added product.
For information on Standing Exceptions and Termination of Exceptions see. Manual Chapter 3033.
Section A: To be Completed by Applicant
Name of Applicant:
Date:
Building:
Room:
Institute or Center:
Phone Number:
List Chemical Name and or Equipment Containing Mercury if applicable:
A.
Chemical Name
Quantity
Size
(example 100 ml)
B.
Name of Equipment Containing Mercury
Quantity
Location of use:
Intended use:
(FRONT)
NIH 2936 (10/12)
NIH ORF Division of Environmental Protection
Application for Special Exception for Procurement and Use of Mercury
(Use prescribed by NIH Manual 3033)
In accordance with Manual Issuance 3033 NIH authorizes limited exceptions for certain scientific and medical uses of
mercury and its compounds for which there are no acceptable alternatives. Examples of such uses may include, but
are not limited to, calibration of measurement instruments; fixatives used in histology; components of existing
equipment that cannot be replaced; research on mercury toxicology; and property that contains mercury as a
necessary component.
APPLICATION PROCESS:
1. Applicant seeking to procure or use mercury added products or mercury containing devices with a total mercury
concentration equal to or greater than 100 parts per billion shall submit a written application for a Special
Exception to the Division of Environmental Protection (DEP), ORFDO.
2. Applicants are required to have the application for the exception reviewed and signed by their Institute or Center
(IC) Scientific Director before submission of the application to the DEP Director.
REVIEW and APPROVAL:
1. The DEP Director or designee shall notify the applicant and IC Scientific Director within three business days of
an approved Special Exception request.
2. If the application is not approve, the DEP Director or designee shall return it to the applicant within ten business
days with an explanation stating why it was not approved and a recommended course of action. The IC
Scientific Director shall be copied on this notification.
3. An approve application is valid for five years.
Special Exception Procurement:
1. The applicant shall provide a copy of the approved special exception application to his or her procurement
official to authorize the procurement of the mercury added product.
For information on Standing Exceptions and Termination of Exceptions see. Manual Chapter 3033.
Section A: To be Completed by Applicant
Name of Applicant:
Date:
Building:
Room:
Institute or Center:
Phone Number:
List Chemical Name and or Equipment Containing Mercury if applicable:
A.
Chemical Name
Quantity
Size
(example 100 ml)
B.
Name of Equipment Containing Mercury
Quantity
Location of use:
Intended use:
(FRONT)
NIH 2936 (10/12)
NIH ORF Division of Environmental Protection
Please provide justification for use of mercury, mercury compounds or equipment containing mercury as in lieu of
using a mercury free alternative product:
Handling and Storage Precautions:
Please refer to the Safety Data Sheet or manufacturer’s recommendation. Always handle in a safe manner to avoid
breakage or releases. Mercury containing compounds when not in use must be secured in closed containers to
prevent spills.
Describe any additional precautions that will be taken to prevent spills or releases during use:
In the event of mercury spill all personnel must evacuate the area. For spills at the main campus notify the NIH Fire
Department by dialing 911. For spills at NIH off-campus facilities call the local Fire Department by dialing 9-911.
Section B: To be Completed by IC Scientific Director
IC Scientific Director Exception Review, Approval and Acknowledgement of responsibility for remediation clean-up costs:
Name:
Signature:
Date:
For DEP Use Only: Date Received
Section C: To be Completed by DEP Director, or designee
DEP Director or designee Review and Approval:
Name:
Signature:
Title:
Date:
Application Approved: Yes
No
If no, provide explanation below and recommended course of action.
Explanation:
Recommended Action:
NIH 2936 (10/12)
(BACK)
Return completed form to
Director, DEP, Bldg13/2S11

Download Form NIH 2936 Application for Special Exception for Procurement and Use of Mercury

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