COLLEGE
OF NATURAL SCIENCES AND MATHEMATICS
SAFETY
INSTRUCTION AND VERIFICATION
(STUDENT
LABORATORY AND/OR FIELD WORK)
TO THE INSTRUCTOR: Please
read the applicable information printed on the “Instructions for Student Safety
Verification Form” to your class (document available in your Department
Office/Issue Room and CNSM Safety Website).
Check off each topic on this form
as you discuss it with them. Write “N/A”
for topics that do not apply. Return
the completed sheet to your Dept. Office or Issue Room. It is your responsibility to describe the
hazards associated with the course and the appropriate health and safety
measures needed to minimize the risks posed by the hazards. This document was designed to facilitate this
task. Throughout the semester, it is
your responsibility to ensure that the appropriate health and safety measures
are followed. Any questions regarding
this safety training and documentation and enforcement should be directed to
the Department Chair, or the CNSM Safety Office (x55623).
TO THE STUDENT: It is
your responsibility to be knowledgeable in the safety‑related matters
associated with this course and to abide by the safety policies and procedures
presented by the instructor. Part of
the evaluation of your performance in this laboratory will be based upon your
strict attention to these safety policies.
Failure to meet these requirements may result in expulsion.
INSTRUCTOR
NAME: ____________________ COURSE: ___________
SECTION NO.: __________
Part I. GENERAL SAFETY
MATTERS: This
entire section is required information for everyone.
____
1.
Right‑to‑know/Hazard Communication – Labeling containers and rooms
____
2.
Material Safety Data Sheets (MSDS)
____ 3. Goggle
policy for liquids, lasers, UV light, flying particles.
____
4.
No eating/drinking/food and no smoking policies
____
5.
Housekeeping/clean-up
____
6.
Conduct in the laboratory or field site **
____ 7.
Reporting of accidents, exposures and injuries (Instructor must turn in an Incident Report Form too)
____
8.
Student medical costs (no coverage!)
Part II.
SAFETY EQUIPMENT AND PROCEDURES:
Points 5 and 6 apply to everyone.
____
1.
Safety shower
____
2.
Eyewash
____
3.
Fire extinguishers
____
4.
Proper Laboratory Attire (closed-toe shoes REQUIRED AT ALL TIMES in labs that
EVER use corrosive/toxic chemicals – NO sandals!)
____
5.
Emergency evacuation route (required information for everyone)
____
6.
Emergency phone procedures (required information for everyone)
____
7.
College safety supply cabinet
____
8.
Chemical and/or biological hood
Part III.
CHEMICAL AND EQUIPMENT HAZARDS: Point 10 applies to everyone. Point 15 may apply to many.
____
1. Chemical storage and incompatibilities
____
2. Proper disposal of chemical wastes
____
3. Use and handling of concentrated acid and
bases
____
4. Use and handling of toxic chemicals &
exposure routes
____
5. Use and handling of carcinogenic chemicals
____
6. Use and handling of radioactive materials
____
7. Use and handling of biohazards
____
8. Use of scientific glassware
____
9. Handling and reporting of chemical spills
____
10.
Proper disposal of broken glassware/sharps (required information for everyone)
____
11.
Use and handling of water reactive chemicals
____
12.
Use and handling of oxidizing and reducing chemicals
____
13.
Use and handling of reproductive toxins
____
14.
Use and handling of compressed and/or liquefied gas
____
15.
Equipment hazards (list the equipment to be used on this line)
____________________________________________________
Part IV.
FIELDWORK AND TRAVEL HAZARDS: (Additional documentation required prior to
departure. See NOTE to instructors
below.)
NOTE: All instructors/trip leaders who conduct field
trips MUST review the current CNSM Field
Trip Safety Manual. This Manual is
available in Department Offices/ Issue Rooms and on the CNSM Safety
website. Prior to the first field
exercise, the instructor/trip leader shall present the applicable portions of
the Manual to the students and require the students to sign a separate training
sheet at that time. You must give the
sign-up sheet to your Dept. Office.
____
1.
Motor vehicle and driver requirements
____
2.
Field Trip Safety Manual (covers equipment, buddy system, emergencies, climate,
terrain, wildlife etc. details.)
** The
CSULB policy states: "Disciplinary action: The University, through
appropriate administrators, may take the following disciplinary actions against
employees or students who violate proper safety procedures willfully or through
negligence. The severity of this action will be determined by circumstances of
the violation:
(a) Oral
reprimand (b) Written reprimand placed
in his/her official folder (c)
Temporary suspension (d) Demotion
(CSULB employee) (e) Dismissal or
expulsion
O/D-FSR
Form
3154-C (alternate)
STU.SFTY.VERIF.FORM.11.O4
TURN OVER FOR
SIGNATURES
INSTRUCTOR
CERTIFICATION
I Certify that I presented the applicable safety and health
information to the students of this class as indicated above based upon the
current CNSM Instructions for Student
Safety Verification Form.
PRINT
INSTRUCTOR’S NAME: _____________________________________________
INSTRUCTOR
SIGNATURE: ________________________________________________ DATE: ___________________
================================================================================================
STUDENT
CERTIFICATION
I hereby
acknowledge that I have been instructed in and understand the applicable safety
and health information, and safe use of materials, equipment and machinery as
given by the instructor for this course as appropriate. I realize that inappropriate behavior and/or
the misuse of equipment, materials etc. can lead to serious injury. I hereby agree to follow all instructions for
student safety as given by my instructor now and in the future. I hereby agree to fully comply at all times
with all CNSM and University policies and procedures associated with safety as
pertains to this course. I hereby agree
to work safely at all times, protecting both myself and those around me. I hereby agree to handle materials,
equipment, machinery and other items identified by the instructor in accordance
with the safety instructions provided during this course. I further agree that
I will not operate any equipment or machinery or use any materials or other
items identified as applicable by the instructor without appropriate
instruction, supervision and understanding of the potential hazards involved. I
understand that I am responsible for medical treatment costs if I am injured in
this class.
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