Environmental Health & Safety Forms

Biological Safety

Documents associated with Biological Safety
Titlesort ascending Description File Name
Vaccinia Vaccination Form

Vaccinia Vaccination Accept/Decline form

PDF icon Vaccinia Immunization Packet.pdf
Site-Specific- Shipping with Dry Ice

After completing the Shipping with Dry Ice e-learning course, the date of completion will be added to your training records found under “My Training” on the Employee Self Service site. Complete this site-specific form with your supervisor or designated work area trainer to verify that you have successfully completed EHS’s e-learning course.  Note: this form is to be maintained in the lab's safety/training records.

PDF icon Site-Specific - Dry Ice training
Site-Specific- Shipping Infectious Substances

After completing the Shipping Infectious Substances e-learning course, the date of completion will be added to your training records found under “My Training” on the Employee Self Service site. Complete this site-specific form with your supervisor or designated work area trainer to verify that you have successfully completed EHS’s e-learning course.  Note: this form is to be maintained in the lab's safety/training records.

PDF icon Site-Specific - SIS training
Site-Specific - Lab Chemical Safety

After completing the Lab Chemical Safety e-learning course, the date of completion will be added to your training records found under “My Training” on the Employee Self Service site.  Complete this site-specific form with your supervisor or designated work area trainer to verify that you have successfully completed EHS’s e-learning course.  Note: this form is to be maintained in the lab's safety/training records.

PDF icon Site-Specific - Lab Chem Training
Site-Specific - Bloodborne Pathogens

After completing the Bloodborne Pathogens e-learning course, the date of completion will be added to your training records found under “My Training” on the Employee Self Service site. Complete this site-specific form with your supervisor or designated work area trainer to verify that you have successfully completed EHS’s e-learning course.  Note: this form is to be maintained in the lab's safety/training records.

PDF icon Site-Specific - Bloodborne Pathogen Training
Select Toxin SOP Template

Template to assist UI labs in writing a lab-specific SOP for the possession/use of exempt quantities of CDC select toxins. 

File SelectToxinSOP.docx
Select Agent Toxin Transfer: Exempt Quantity

This document is to ensure each Principal Investigator (PI) who possesses exempt quantities of Select Agent Toxins understands the allowable maximum exempt quantities s/he can possess, as specified by the federal regulations on Select Agents (42 CFR Part 73); and that s/he only transfer exempt quantities of toxin if the receiver has a legitimate need (reasonably justified by a prophylactic, protective, bona fide research or other peaceful purpose) to handle or use the toxin(s).

PDF icon PIexemptquantTransfer.pdf
Select Agent Toxin Inventory Record Form

Inventory form for exempt quantities of select agent toxins.

PDF icon SelectAgentToxinInventoryRecord.pdf
Select Agent Toxin Exemption Declaration

This document is a list of select agent toxins and their exempt quantity limits and must be signed by each Principal Investigator (PI) who possesses exempt quantities of CDC Select Agent Toxins to ensure the PI understands the allowable maximum exempt quantities s/he can possess, as specified by the federal regulations on Select Agents (42 CFR Part 73).

PDF icon PIexemptquantdeclaration.pdf
Select Agent Registration - Internal Form

Use this form to apply for use of select agents in the CCOM BSL3 laboratories.  The form must be submitted to Haley Sinn, BSO in the Environmental Health & Safety Office, 100 EHS.

Microsoft Office document icon SA Internal Reg Form.doc
PPE - Research Laboratory Hazard Assessment Tool

Personal Protective Equipment hazard assessment tool

PDF icon labppetool form final.pdf
Incident Investigation Form

This form should be used to investigate a work related employee injury or illness. 

PDF icon UI Incident Investigation Form.pdf
Human Pluripotent Cell Application

This form should be used to register all use of human embryonic stem cells and/or human pluripotent cells.

Microsoft Office document icon Human Pluripotent Cell Application
Hepatitis B Vaccination Survey

This survey is to be completed when consenting or declining to receive the Hepatitis B vaccination.

PDF icon Hepatitis B Vaccination Survey Instructions
Bloodborne Pathogens: Exposure Control Plan

Template to assist departments in the completion of an exposure control plan.

Microsoft Office document icon Bloodborne Pathogen Exposure Control Template
Bloodborne Pathogens: At Risk Assessment

This form is to assist in the identification of staff at risk for exposure to bloodborne pathogens or other potentially infectious material.

Microsoft Office document icon Bloodborne At Risk Assessment.doc
Bloodborne Pathogen Annual Program Review

Form to assist in documentation that the BBP exposure control plan is reviewed annually.

Microsoft Office document icon Annual Program Review

Chemical Safety

Documents associated with Chemical Safety
Titlesort ascending Description File Name
Training Needs Assessment

This form should be used to document current laboratory staff and their activities within the lab for purposes of determining required training.

File Training Needs Assessment Template
Site-Specific - Lab Chemical Safety

After completing the Lab Chemical Safety e-learning course, the date of completion will be added to your training records found under “My Training” on the Employee Self Service site.  Complete this site-specific form with your supervisor or designated work area trainer to verify that you have successfully completed EHS’s e-learning course.  Note: this form is to be maintained in the lab's safety/training records.

PDF icon Site-Specific - Lab Chem Training
PPE - Respirator Dust Mask Lab Evaluation Request

 Request for evaluation of appropriate respirator/dust mask use in labs.

PDF icon Respiratory Request Form
PPE - Research Laboratory Hazard Assessment Tool

Personal Protective Equipment hazard assessment tool

PDF icon labppetool form final.pdf
Nanomaterials (NMs) Hazard Assessment Data Capture Form PDF icon Nanomaterials form.pdf
GHS Training Notice

This one-page flyer titled "Notice of Required Regulatory Training for GHS" may be distributed and posted in laboratories and workplaces that handle chemicals.  The flyer describes the training module employees are required to complete by November 2013, so they are aware of changes to chemical labels and (material) safety data sheets.

PDF icon GHS Training Notice.pdf
Eyewash testing/flushing verification - weekly

Form used to document periodic testing/flushing of the eyewash station. 

PDF icon WEEKLY Eyewash Verification
Eyewash testing/flushing verification - monthly

Form used to document periodic testing/flushing of the eyewash stations. 

PDF icon Monthly eyewash verification.pdf
EHS Assistant Chemical Inventory Template

Excel file to be filled out by labs when they need inventory uploaded to the EHS Assistant.

Office spreadsheet icon EHS Assist Chemical Inventory Template
Chemical Hygiene Plan - Annual Review

Form to document annual review of the Chemical Hygiene Plan

Microsoft Office document icon Chemical Hygiene Plan - Annual Review.doc

Occupational Safety

Documents associated with Occupational Safety
Titlesort ascending Description File Name
Work Site-Specific Training - PPE Awareness PDF icon Site Specific - PPE Training
Respiratory Program Evaluation

Respiratory Program Evaluation Form

PDF icon Respiratory Program Evaluation Guide.pdf
Respirator Medical and Fit Test Forms

Respirator Qualitative and Quantitative fit test and Medical Questionnaire forms and UI Policy

PDF icon RespMedPolicyandFTForms.pdf
Operations PPE Hazard Assessment

This form is used to certify the hazard assessment that determines if hazards are present which necessitate the use of personal protective equipment.

PDF icon Certification Of Hazard Assessment For PPE Use.pdf
Incident Investigation Form

This form should be used to investigate a work related employee injury or illness. 

PDF icon UI Incident Investigation Form.pdf
Hearing Conservation - Refusal of Hearing Test Form

 Complete this form when declining a hearing test.

PDF icon Hearing Conservation - Refusal of Hearing Test Form.pdf
GHS Training Notice

This one-page flyer titled "Notice of Required Regulatory Training for GHS" may be distributed and posted in laboratories and workplaces that handle chemicals.  The flyer describes the training module employees are required to complete by November 2013, so they are aware of changes to chemical labels and (material) safety data sheets.

PDF icon GHS Training Notice.pdf
Exposure Records Request Form

OSHA regulation form to be completed for employee exposure and medical records.

PDF icon exposure records access form.pdf
Authorization Table for Required Respirator Use

Authorization Table for Required Respirator Use form

PDF icon Authorization Table for Required Respirator Use.pdf

Radiation Safety Webforms

Radiation Safety

Documents associated with Radiation Safety
Titlesort ascending Description File Name
RDRC Form

Radioactive Drug Research Committee Form - Use this form to apply for authorization to conduct basic research regarding the metabolism, distribution, and localization of a radioactive drug in humans (as defined by 21 CFR 361.1) in preparation for applying for an IND

Microsoft Office document icon rdrcform.doc
Radioactive Materials Transferred on Campus

Form to transfer radioactive material to another approved user on-campus.

Microsoft Office document icon On Campus Rad Transfer Form.doc
Pregnancy Declaration and Prenatal Radiation Exposure Form

EHS has established a Pregnancy Declaration Program as required by State radiation safety regulations. This program provides information and consultation concerning prenatal radiation exposure as well as dose monitoring of the embryo/fetus at the mother & rsquo's request.

Microsoft Office document icon PregDeclarationandPrenatalRadExposForm.doc
PPE - Research Laboratory Hazard Assessment Tool

Personal Protective Equipment hazard assessment tool

PDF icon labppetool form final.pdf
MRPC Laser Form for Class 3b and 4 Lasers

Medical Radiation Protection Committee (MRPC) Application for Medical Research Use of Radiation Form. This form is to be used for projects involving research related use of Class 3b & 4 lasers.

Microsoft Office document icon MRPC - Laser Form for Class 3b and 4 Lasers.doc
MRPC Additional Internal Radiation Form

Complete this form when radioactive materials will used inside the body for research-related diagnostic procedures.

Microsoft Office document icon MRPC Additional Internal Rad Form.doc
MRPC - Short Form

Medical Radiation Protection Committee (MRPC) Applications for Medical Research Use of Radiation

Microsoft Office document icon MRPC Short Form Diagnostic
MRPC - Long Form Therapeutic

Medical Radiation Protection Committee (MRPC) Applications for Medical Research Use of Radiation Use this form for Theraputic Radiation Procedures

Microsoft Office document icon MRPCLongFormTherapeutic.doc
MRPC - Long Form Diagnostic Example

Medical Radiation Protection Committee (MRPC) Applications for Medical Research Use of Radiation

Microsoft Office document icon MRPC Long form Diagnostic Example
MRPC - Long Form Diagnostic

Medical Radiation Protection Committee (MRPC) Applications for Medical Research Use of Radiation Use this form for New Applications involving Diagnostic Radiation Procedures

Microsoft Office document icon MRPC Long form diagnostic
MRPC - Additional External Radiation Form

Medical Radiation Protection Committee (MRPC) Applications for Medical Research Use of Radiation Complete this form when radiation sources will be used outside the body for research-related diagnostic procedures

Microsoft Office document icon MRPC Additional External Rad Form.doc
Laser Registration for Class 3b and Class 4 Lasers

Form to register Class 3b and Class 4 Lasers.

Microsoft Office document icon Laser Registration for Class 3b and Class 4 Lasers.doc
HRSRG – Radioactive Material Devices

Hospital Radiation Safety Review Group (HRSRG) Applications for Routine Clinical Use of Radioactive Material Forms. Use this application for clinical use of radioactive materials devices in the UIHC.

Microsoft Office document icon HRSRG - Radioactive Material Devices
HRSRG - Compound Radiopharmaceutical Form

Hospital Radiation Safety Review Group (HRSRG) Application for Routine Clinical Use of Radioactive Material. Use this application for Clinical use of Compounded Radiopharmceuticals in the UIHC.

PDF icon HRSRG Compound radio form.pdf
BSRPC - Survey Receipt Utilization and Disposal Form

Use this form to document radioactive inventory and survey results.

PDF icon BSRPC – Survey Receipt Utilization and Disposal Form.pdf
BSRPC - Methodology Amendment

Basic Science Radiation Protection Committee (BSRPC) Applications for Non-Medical Use of Radioactive Materials Use this form to add radionuclides and/or new methodolgies to an existing authorization.

Microsoft Office document icon Non-Human Form2 rev090717.doc
BSRPC - Application Cancellation Form

Basic Science Radiation Protection Committee (BSRPC) Applications for Non-Medical Use of Radioactive Materials Use this form to cancel your application for Non-Human Use of Radioactive Materials

Microsoft Office document icon BSRP - Application Cancellation Form.doc
BSRPC - Administrative Amendment

Basic Science Radiation Protection Committee (BSRPC) Applications for Non-Medical Use of Radioactive Materials Use this form to amend possession limits of previously approved radionuclides, use and storage locations, and/or add or delete personnel authorized to work with radioactive material.

Microsoft Office document icon Non-Human form3 rev090717.doc
BSRPC - Authorization Request

Basic Science Radiation Protection Committee (BSRPC) Applications for Non-Medical Use of Radioactive Materials Form Use this form when making initial application for approval to use radioactive materials for non-medical purposes.

Microsoft Office document icon Non-Human form1rev 11-5-13.doc

Waste / Environmental Webforms

Waste / Environmental

Titlesort ascending Description File Name
Universal Waste - Mercury Containing Equipment Labels

A template for printing the Universal Mercury Containing Equipment. (Avery Label #5164, printed in color)

Microsoft Office document icon UN mercury equip lbl (Avery 5164).doc
Universal Waste - Lamps Labels

A template for printing the Universal Waste Lamps. (Avery Label #5164, printed in color)

Microsoft Office document icon UN lamps (Avery 5164).doc
Universal Waste - Batteries Label

Template for printing the Universal Waste Batteries. (Avery Label #5164, printed in color)

Microsoft Office document icon UN batteries LBL (Avery 5164).doc
Small Hazardous Waste Labels

Template for printing the Small Hazardous Waste Label. (Avery Label #5162)

Microsoft Office document icon Labels - Small Hazardous Waste.doc
Site Specific - Biohazardous Waste Management Training

Completion of both the e-Learning course and department requirements constitutes certification that the individual has been trained per 49 CFR 172.704.

 

PDF icon Site Specific W524HZ.pdf
Large Hazardous Waste Labels

Template for large hazardous waste labels can be printed out on Avery label # 5168, 8168 or 95935. 

File large waste label_quarter sheet.docx

VAMC

Documents associated with VAMC
Titlesort ascending Description File Name
VAMC - Radioactive Use Methodology Amendment Form 2

Radioactive materials use - Methodology Amendment form

Binary Data
VAMC - Radioactive Use Authorization Request Form 1

Radioactive materials use in basic sciences authorization request form.

Microsoft Office document icon vamcform1.doc
VAMC - Radioactive Use Administrative Amendment Form 3

Radioactive materials use in basic sciences - administrative form.

Microsoft Office document icon vamcform3.doc
VAMC - Radiation Safety General Operational Procedures

Radiation Safety General Operational Procedures

PDF icon VAMCGenOpPro.pdf
VAMC - Pregnancy Declaration Form

Pregnancy Declaration Form

Microsoft Office document icon vamcpregform.doc
VAMC - NIH Guidelines for Research Involving Recombinant DNA

NIH Guidelines for Research Involving Recombinant DNA Molecules

PDF icon VAMC NIH guidelines 2014hs cm.pdf
VAMC - Dosimeter Request for Service

Dosimeter request for service form

Microsoft Office document icon vamcdaddform.doc
VAMC - Dosimeter Change in Service

Dosimeter change in service form

Microsoft Office document icon vamcdchform.doc