Healthcare Facility Hazardous Material Declaration
Facility Information
Facility Name
Address
City
State
ZIP Code
Contact Person
Phone
Email
Hazardous Material Information
Material Name
Chemical Name/Description
Quantity
Storage Location
Hazard Class
Physical State
Solid
Liquid
Gas
Container Type
Safety Data Sheet (SDS) Available
Yes
No
Additional Information
Hazardous Material Handling Procedures
Emergency Response Plan
Declaration
Name
Title
Date
Signature