Environmental Health & Safety Forms
Biological Safety
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Description | File Name |
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Vaccinia Vaccination Form |
Vaccinia Vaccination Accept/Decline form |
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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. |
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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. |
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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. |
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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. |
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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. |
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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). |
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Select Agent Toxin Inventory Record Form |
Inventory form for exempt quantities of select agent toxins. |
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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). |
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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. |
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PPE - Research Laboratory Hazard Assessment Tool |
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Human Pluripotent Cell Application |
This form should be used to register all use of human embryonic stem cells and/or human pluripotent cells. |
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Hepatitis B Vaccination Survey |
This survey is to be completed when consenting or declining to receive the Hepatitis B vaccination. |
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Bloodborne Pathogens: Exposure Control Plan |
Template to assist departments in the completion of an exposure control plan. |
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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. |
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Bloodborne Pathogen Annual Program Review |
Form to assist in documentation that the BBP exposure control plan is reviewed annually. |
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Chemical Safety
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Description | File Name |
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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.
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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. |
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PPE - Research Laboratory Hazard Assessment Tool |
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Nanomaterials (NMs) Hazard Assessment Data Capture Form |
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Eyewash testing/flushing verification - Weekly |
Form used to document periodic testing/flushing of the eyewash station. |
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Eyewash testing/flushing verification - Monthly |
Form used to document periodic testing/flushing of the eyewash stations. |
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EHS Assistant Chemical Inventory Template |
Excel file to be filled out by labs when they need inventory uploaded to the EHS Assistant. |
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Chemical Hygiene Plan - Annual Review |
Form to document annual review of the Chemical Hygiene Plan |
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Waste / Environmental Webforms
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Request to Test Unknown |
Radioactive Waste Pickup Request |
Chemical Waste Pickup Request |
Waste / Environmental
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Description | File Name |
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Universal Waste - Mercury Containing Equipment Labels |
A template for printing the Universal Mercury Containing Equipment. (Avery Label #5164, printed in color) |
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Universal Waste - Lamps Labels |
A template for printing the Universal Waste Lamps. (Avery Label #5164, printed in color) |
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Universal Waste - Batteries Label |
Template for printing the Universal Waste Batteries. (Avery Label #5164, printed in color) |
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Small Hazardous Waste Labels |
Template for printing the Small Hazardous Waste Label. (Avery Label #5162) |
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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.
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Large Hazardous Waste Labels |
Template for large hazardous waste labels can be printed out on Avery label # 5168, 8168 or 95935. |
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VAMC
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Description | File Name |
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VAMC - Radioactive Use Methodology Amendment Form 2 |
Radioactive materials use - Methodology Amendment form |
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VAMC - Radioactive Use Authorization Request Form 1 |
Radioactive materials use in basic sciences authorization request form. |
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VAMC - Radioactive Use Administrative Amendment Form 3 |
Radioactive materials use in basic sciences - administrative form. |
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VAMC - Radiation Safety General Operational Procedures |
Radiation Safety General Operational Procedures |
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VAMC - Pregnancy Declaration Form |
Pregnancy Declaration Form |
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VAMC - NIH Guidelines for Research Involving Recombinant DNA |
NIH Guidelines for Research Involving Recombinant DNA Molecules |
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VAMC - Dosimeter Request for Service |
Dosimeter request for service form |
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VAMC - Dosimeter Change in Service |
Dosimeter change in service form |
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