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Use these forms to communicate required information to Environment, Health & Safety.
| Animal exposure / Vivarium | ||
|---|---|---|
| Vivarium safety information Forms: |
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| 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 | (PDF) | |
| Asbestos | ||
| Asbestos information Forms: |
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| Asbestos Project Information Sheet | ||
| Biosafety | ||
| Biosafety information Forms: |
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| Biosafety Forms | ||
| Confined space | ||
| Confined space information Forms: |
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| Confined Space Entry Permit | (PDF) | |
| Routine Confined Space Entry Log | (PDF) | |
| Controlled Substances | ||
| Controlled substances information Forms: |
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| 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) | |
| Environmental Protection | ||
| Environmental Protection 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 | (PDF) | (Word) |
| Ergonomics | ||
| Ergonomics information Forms: |
||
| Computer Ergonomic Review Tool | (PDF) | (Word) |
| Ergonomic Resources Fund Request | (PDF) | (Word) |
| Food facility permit applications | ||
| Temporary food facility information Forms: |
||
|
Off-Campus / Commercial Temporary |
(PDF) | |
| Non-Profit and Student Organizations Temporary Food Facility Permit Application |
(PDF) | |
| 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 Inspection | (PDF) | (Excel) |
| Supervisor's Safety Meeting | (PDF) | (Word) |
| Laser safety | ||
| Laser safety information Forms: |
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| Laser Safety Forms |
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| Lead-Based Paint | ||
| Lead-Based Paint Management Program Forms: |
||
| Lead-Based Paint Project Information Sheet |
||
| Lockout / Blockout | ||
| Lockout/ blockout information Forms: |
||
| Lockout / Blockout training form | (PDF) | (Word) |
| PPE | ||
| Personal protective equipment (PPE) information Forms: |
||
| PPE Hazard Assessment (PDF) | (English) (Spanish) | |
| Pest control | ||
| Pest Control Forms: |
||
| Request Pest Control Services | (PDF) | |
| Residential apartments and halls: EH&S Pest Management Preparation List | (PDF) | (Word) |
| Radiation safety | ||
| Radiation safety information Forms: |
||
| Radiation Safety Forms: For Medical Center Employees | ||
| Radiation Safety Forms: Research Employees | ||
| Report a safety concern | ||
| Report a Safety Concern to Environment, Health & Safety Forms: |
||
| Report a Safety Concern | ||
| Report a work-related injury, illness, or exposure | ||
| What to Do if a Work-Related Injury, Illness, or Exposure Occurs Forms: |
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| Employee's Occupational Incident Report | ||
| Supervisor's Occupational Incident Report | ||
| 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 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) |
| Lab Self-Audit Form | (PDF) | |
| Respiratory protection | ||
| Respiratory protection information Forms: |
||
| COEM Registration and Charge Document | (PDF) | (Word) |
| Medical Evaluation Questionnaire for Respirator-Use Certification | (PDF) | (Word) |
| Risk management (liability insurance) | ||
| Risk management insurance information Forms: |
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| Risk Management Forms | ||
| Safety award for excellence | ||
| Safety Award For Excellence (SAFE) information Forms: |
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| Nomination form | ||
| Workers' compensation | ||
| Workers' compensation information Forms: |
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| 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 | (PDF) | (Word) |
