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Environment, Health & Safety Forms

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

Select a category:


Animal exposure / Vivarium
Vivarium safety information

Forms:

Form A – Risk Assessment Work Evaluation Questionnaire for Employees or Affiliates with Animal Contact (PDF)  
Form B – Medical History Questionnaire for Employees or Affiliates with Animal Contact


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(PDF)  
Asbestos
Asbestos information

Forms:

Asbestos Project Information Sheet


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Biosafety
Biosafety information

Forms:

Biosafety Forms


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Confined space
Confined space information

Forms:

Confined Space Entry Permit (PDF)  
Routine Confined Space Entry Log


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(PDF)  
Controlled Substances
Controlled substances information

Forms:

CS Usage Log Sheet, additional page (PDF)  
Sample CS Usage Log Sheet (PDF)  
CS Self-assessment Audit Sheet (PDF)  
Deactivation of Controlled Substances Use Authorization (PDF)  
Personnel Screening Data Sheet (PSDS) - Applicant (PDF)  
Personnel Screening Data Sheet (PSDS) - Principal investigator (PDF)  


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Environmental Protection
Environmental protection & pollution prevention information

Forms:

Petroleum Container Inspection Checklist (PDF) (Word)
Refrigerant: Contractor Input (PDF) (Word)
Refrigerant: Cylinder Input (PDF) (Word)
Refrigerant: Equipment Input (PDF) (Word)
Refrigerant: Recover/Recycling Unit Input (PDF) (Word)
Refrigerant: Service Order


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(PDF) (Word)
Ergonomics
Ergonomics information

Forms:

Ergonomic Resources Fund Request


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(PDF) (Word)
First Aid Kits
Emergency preparedness

Forms:

First Aid Kit approved list for UCSD


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(PDF)  
Food facility permit applications
Temporary food facility information

Forms:

Off-Campus / Commercial Temporary
Food Facility Permit Application

(PDF)  
Non-Profit and Student Organizations
Temporary Food Facility Permit Application


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(PDF)  
Hazardous waste
Hazardous waste information

Forms:

Hazardous Waste Generator Number Application
Online Waste Tag Program (OTP)


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Injury & Illness Prevention Program
IIPP information

Forms:

Accident Investigation (how and why it happened) (PDF) (Word)
Employee Safety Recommendation (PDF) (Word)
Environment of Care / Patient Safety Rounds Tool (PDF)  
Hazard Identification (PDF) (Word)
New Laboratory Worker Checklist (PDF) (Word)
Office Safety Inspection (PDF) (Word)
Shop & Studio Safety Inspection Report (PDF) (Excel)
Shop & Studio Safety Inspection Checklist (PDF) (Excel)
Supervisor's Safety Meeting


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(PDF) (Word)
Ladders and lifts
Ladder and lifts safety information

Forms:

Ladder inspection form


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(PDF)  
Laser safety
Laser safety information

Forms:

Laser Safety Forms


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Lead-Based Paint
Lead-Based Paint Management Program

Forms:

Lead-Based Paint Project Information Sheet


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Lockout / Blockout
Lockout/ blockout information

Forms:

Lockout / Blockout training form


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(PDF) (Word)
PPE
Personal protective equipment (PPE) information

Forms:

PPE Hazard Assessment English (PDF) Spanish (PDF)
Laboratory Hazard Assessment Tool (LHAT) (PDF) (Word)
Embroidered Lab Coat Fitting Form (PDF) (Word)

Lab Coat Laundry Envelope Request Form

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Pest control
Pest Control information

Forms:

Request Pest Control Services (PDF)  
Residential apartments and halls: EH&S Pest Management Preparation List


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(PDF) (Word)
Radiation safety
Radiation safety information

Forms:

Radiation Safety Forms: Health System Employees
Radiation Safety Forms: Research Employees


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Report a safety concern
Report a Safety Concern to Environment, Health & Safety

Forms:

Report a Safety Concern


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Report a work-related injury, illness, or exposure
What to Do if a Work-Related Injury, Illness, or Exposure Occurs

Forms:

Employee's Occupational Incident Report    
Supervisor's Occupational Incident Report


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Research/ Laboratory Safety
Laboratory/ Research safety information

Forms:

Chemical Abbreviations and Annotations (PDF) (Word)
Controlled Substance: Personnel Screening Data Sheet - Individual
(for lab contacts and other individuals)
(PDF)  
Controlled Substance: Personnel Screening Data Sheet - PI only
(for principal investigators only)
(PDF)  
Decontamination Clearance Request
First Aid Kit approved supplied list (PDF)  
Laboratory Hazard Assessment Tool (LHAT) (PDF) (Word)
Laboratory Relocation or Closure Notification
Magnet Registration (PDF) (Word)
New Laboratory Worker Checklist (PDF)  
Principal Investigator Information (PDF) (Word)
Proposed Project Checklist for Minors Performing Research in Laboratories (PDF) (Word)
Lab Self-Audit Form


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(PDF)  
Respiratory protection
Respiratory protection information

Forms:

Hazard Evaluation - For Respirator Use Request    
COEM Registration and Charge Document (PDF) (Word)
Medical Evaluation Questionnaire for Respirator-Use Certification


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(PDF) (Word)
Risk management (liability insurance)
Risk management insurance information

Forms:

Risk Management Forms


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Safety award for excellence
Safety Award For Excellence (SAFE) information

Forms:

Nomination form


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Special Events
Special events information

Forms:

Special Events Checklist Tool - On-Campus Events


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(PDF)  
Workers' compensation
Workers' compensation information

Forms:

Designation of Physician (PDF) (Word)
Employee's Occupational Incident Report    
Supervisor's Occupational Incident Report    
OSHA Form 300A: Summary of Work-Related Injuries and Illness    
Transitional Return to Work Program Guidelines


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(PDF) (Word)