COLLEGE OF NATURAL SCIENCES & MATHEMATICS

 

 

PROJECT SAFETY REVIEW & AUTHORIZATION

 

Applicant: _____________________________

 

Names of all workers involved in the project (including students, staff, or others). The alternate contact must be able to answer questions relating to the project.
List buildings, rooms and outlying locations to be used:___________________________________________
Department: __________________
Telephone: _____________
Project title(s): _____________________
___________________________________________________________________________

 

Alternate Contact: _____________________________________________ Telephone:_________________ _____________________________________________________________________________________ _____________________________________________________________________________________

 

 

 

___________________________________________________________________________________ _________________________________________________________________________________

3. (a) Describe hazardous activities associated with the project (chemical, physical, or biological hazards): _________________________________________________________________________________ ____________________________________________________________________________________

___________________________________________________________________________________

(b) Describe training plan:_______________________________________________________________ __________________________________________________________________________________

(c) List safety procedures, equipment, etc. used to protect against hazards listed in item (4a) above: ___________________________________________________________________________________

__________________________________________________________________________________

(d) SPECIFICALLY REGULATED ACTIVITIES: Please circle all of the following activities associated with the project:

RADIOACTIVE MATERIALS/RADIATION MACHINES SCUBA DIVING OFF-CAMPUS DEMONSTRATIONS ANIMAL STUDIES HUMAN BLOOD/TISSUE TRAVEL TRANSPORT OF HAZARDOUS MATERIALS (live vertebrate) 5. Are you planning to set-up or present a demonstration for Kaleidoscope or other outreach activity? Circle one: YES NO 6.

APPLICANT SIGNATURE: _______________________________

DATE: _________________

College Health and Safety Committee review & Approval: Committee-mandated Requirements/Conditions: _________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________ __________________ Dept. Safety Chair Signature Date _____________________________________ __________________ CNSM Safety Chair Signature Date _____________________________________ __________________ Applicant Signature Date (INSTRUCTIONS ON BACK OF FORM rev. 9/96