What is your LAST NAME? ____________________ FIRST?_____________ Department? ___________

RETURN TO SAFETY OFFICE WITHIN 7 DAYS FROM TODAY – OR YOU MAY LOSE YOUR JOB!!!

CSULB COLLEGE OF NATURAL SCIENCES AND MATHEMATICS

SAFETY PROGRAM FORM

DIRECTIONS:

· YOU MUST ANSWER EVERY QUESTION ON THIS FORM. If you don’t know the answer, ask your supervisor.

· YOU MUST PERSONALLY HAND the completed form to CNSM SAFETY OFFICE personnel. The Safety Office is in PH3-018 WITHIN 7 DAYS OF TODAY’S TRAINING. You may NOT slip it under the door; put it in our mailbox; give it to your professor, issue room, Dept. office etc. YOU MUST PERSONALLY GIVE IT TO SAFETY OFFICE STAFF.

· SAFETY OFFICE PERSONNEL WILL GIVE YOU A QUIZ ON THE CONTENTS OF THE SAFETY TRAINING. Your training is not complete until you have passed the quiz.

· IF YOU DO NOT PASS THE QUIZ YOU WILL BE REQUIRED TO PARTICIPATE IN ADDITIONAL TRAINING.

2. What is your JOB? (circle one): TA, GA, STAFF, FAC, WS, SA, 495/6 student, MASTER’S STUDENT RESEARCH, VOLUNTEER, FOUNDATION, OTHER:__________

3. Circle one: I will receive a STIPEND / PAYCHECK / NO MONEY for this work.

4. If you will receive money, will you be filling out a TIMESHEET? Circle one: YES / NO.

5. If you will receive money, where will it come from? Circle one: UNIVERSITY / FOUNDATION

6. Who is your SUPERVISOR? ______________________________________________________________

7. Will you use CHEMICALS (even ones like oil, buffers, etc.) while working? Circle one: YES / NO.

8. Will YOU be supervising anyone who will be using chemicals? Circle one: YES / NO.

9. Ask your supervisor(s) if your work will require you to be involved with any of the following, then circle "YES" or "NO" for each item listed. WILL YOU USE :

a) EQUIPMENT (ultracentifuges, machine tools etc.?............ YES NO

b) RADIOACTIVE MATERIALS OR X‑RAYS? ................. YES NO

c) HUMAN BODY FLUIDS or tissues? ............................... YES NO

d) LASERS or ultraviolet light? ............................................ YES NO

e) LIVE ANIMALS FOR RESEARCH? ............................... YES NO

f) MICROBIAL AGENTS (BACTERIA, VIRUSES ETC.).... YES NO

g) HIGH VOLTAGE equipment? ......................................... YES NO

(Please turn over)

h) CRYOGENIC MATERIALS? ......................................... YES NO

i) REGISTERED Cal/OSHA CARCINOGENS? ................. YES NO

j) COMPRESSED GAS CYLINDERS? .............................. YES NO

k) FIELD WORK/DRIVING? ................................................ YES NO

l) SCUBA DIVING/WATERCRAFT USE.?........................... YES NO

m) ANY OTHER HAZARDOUS ACTIVITIES? Describe: ________________________

10. Did you have any EXPERIENCE with any of the above (a through m) before you were employed here? Please list by letter; for example: "a, f, g": ____________________________

11. Will YOU supervise any other people (including students!) as they do any of the above (a through m)? Circle one: YES / NO. If "YES", which of the above will they be doing? Please list: ________________

PARTICIPATION AGREEMENT

I have received and read the CNSM Safety Program Manual. I have received live safety training from CNSM Safety Office personnel (or viewed the appropriate CNSM Safety Program Video). I understand my rights and obligations as an employee, student, volunteer and/or supervisor under the provisions of the Cal/OSHA "Right-to-Know" hazard communication regulations. I agree to work at all times in complete accordance with all Manual policies and procedures, and to protect the health and safety of myself and those around me. I will not knowingly undertake a potentially hazardous task for which I have not been adequately trained. I will not direct others to perform a potentially hazardous activity unless that individual has been trained and has demonstrated adequate skill to perform that activity safely. I am aware of the environmental, health and safety resources provided by the University, College and the Department, and will use them as necessary.

SIGNATURE:____________________________________________ DATE:____________________

REMEMBER:

· WITHIN 7 DAYS FROM RECEIVING TRAINING, YOU MUST PERSONALLY HAND OVER THIS FORM TO SAFETY OFFICE PERSONNEL IN PH3-018!

· YOUR TRAINING IS NOT COMPLETE UNTIL YOU HAVE TAKEN AND PASSED THE QUIZ!

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