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Department Index

Environment, Health & Safety Forms

Summary: Use these forms to communicate required information to Environment, Health & Safety.

Select a category:

Accident and injury reporting
What to Do if a Work-Related Injury, Illness, or Exposure Occurs Forms:
Employee Injury Incident Report Back to top	(PDF)	(Word)
Animal exposure / Vivarium
Vivarium safety information Forms:
Form A – Risk Assessed Work Evaluation Questionnaire for Employees or Affiliates with Animal Contact	(PDF)	(Word)
Form B – COEM Registration & Charge Document	(PDF)	(Word)
Form C – Medical History Questionnaire for Employees or Affiliates with Animal Exposure Back to top	(PDF)	(Word)
Asbestos
Asbestos information Forms:
Asbestos Project Information Sheet Back to top	(PDF)	(Word)
Biosafety
Biosafety information Forms:
Go to Biosafety Forms Back to top
Confined space
Confined space information Forms:
Confined Space Entry Permit	(PDF)
Routine Confined Space Entry Log Back to top	(PDF)
Controlled substances
Controlled substances information Forms:
Go to Controlled Substances Forms Back to top
Ergonomics
Ergonomics information Forms:
Computer Ergonomic Review Tool Back to top	(PDF)	(Word)
Food facility permit applications
Temporary food facility information Forms:
Non-Profit and Student Organizations Temporary Food Facility Permit Application Back to top	(PDF)
Hazardous materials business plan
Hazardous materials business plan information Forms:
Hazardous Materials Business Plan Back to top	(PDF)	(Word)
Hazardous waste
Hazardous waste information Forms:
Hazardous Waste Generator Number Application
Hazardous Waste Collection Request Back to top
Injury & Illness Prevention Program
IIPP information Forms:
Employee Safety Recommendation	(PDF)	(Word)
Facility Safety Inspection	(PDF)	(Word)
New Laboratory Worker Checklist	(PDF)	(Word)
Hazard Identification	(PDF)	(Word)
Accident Investigation (how and why it happened)	(PDF)	(Word)
Office Safety Inspection	(PDF)	(Word)
Supervisor's Safety Meeting	(PDF)	(Word)
UCSD Medical Center Facilities Inspection Back to top	(PDF)	(Word)
Laboratory safety
Laboratory safety information Forms:
Chemical Abbreviations and Annotations	(PDF)	(Word)
Controlled Substances forms
Decontamination Clearance Request
Laboratory Relocation or Closure Notification
Magnet Registration	(PDF)	(Word)
New Laboratory Worker Checklist	(PDF)	(Word)
Principal Investigator Information	(PDF)	(Word)
Proposed Project Checklist for Minors Performing Research in Laboratories	(PDF)	(Word)
Laboratory Self-Audit Form Back to top	(PDF)	(Word)
Laser safety
Laser safety information Forms:
Laser Use Authorization (LUA) Application	(PDF)	(Word)
Laser User Enrollment	(PDF)	(Word)
Laser Use Authorization Amendment
Laser Safety Eye Exam	(PDF)
Laser Equipment Registration Back to top	(PDF)
Lockout / Blockout
Lockout/ blockout information Forms:
Lockout / Blockout training form Back to top	(PDF)	(Word)
Pest services
Pest services information Forms:
Residential apartments and halls: EH&S Pest Management Preparation List	(PDF)	(Word)
All other (non-residential) UCSD facilities: Pest Management Request Back to top	(PDF)
Radiation safety
Radiation safety information Forms:
Go to Radiation Safety Forms Back to top
Report a safety concern
Environment, health & safety information Forms:
Report a Safety Concern Back to top
Report a work-related injury, illness, or exposure
What to Do if a Work-Related Injury, Illness, or Exposure Occurs Forms:
Employee Incident Report Back to top	(PDF)	(Word)
Respiratory protection
Respiratory protection information Forms:
COEM Registration and Charge Document	(PDF)	(Word)
Medical Evaluation Questionnaire for Respirator-Use Certification Back to top	(PDF)	(Word)
Risk management
Risk management insurance information Forms:
Go to Risk Management Forms Back to top
Safety award for excellence
Safety Award For Excellence (SAFE) information Forms:
Safety Award For Excellence Nomination Back to top
Workers' compensation
Workers' compensation information Forms:
Designation of Physician	(PDF)	(Word)
Employee Incident Report	(PDF)	(Word)
OSHA Form 300A: Summary of Work-Related Injuries and Illness for 2007 Back to top	(PDF)