Forms
- Biological Safety
- Ergonomics
- Industrial Hygiene
- Laboratory Safety
- Radiation Safety
- University Employee Occupational Health Clinic
- Workers' Compensation
| Biological Safety Forms | |
|---|---|
| Form | Description |
| Laboratory Safety Plan | Laboratory Safety Plan: Includes Schedule F: Biological Hazards; Schedule G: Registration of Recombinant DNA Experiments; Schedule H: Use of Transgenic Animals or Plants |
| Select Agent Destruction | Contact EHS to verify the destruction procedure and arrange for an EHS witness. Complete this form for the final destruction of your Select Agent or Toxin stocks. |
| Select Agent Registration | Online registration with EHS of select agents in your possession. |
| Required Entryway Sign for BSL-2 Labs | Sign must be printed on a color printer and contact information completed in entirety. Contact EHS for alternative sizes. |
| BSL-2 Checklist | Use this Biosafety Level 2 checklist to designate new BSL-2 space at UNC-Chapel Hill. Print and complete the first two pages of the checklist, then return it to CB #1650. For a detailed description of each item on the first page, hold down "control" on your keyboard while clicking on that item. This checklist is designed to answer common/general questions during your set-up process. |
| IBC Registration Forms | Schedule G (Registration of Recombinant DNA Experiments), Schedule H (Use of Transgenic Animals or Plants), and Appendix 10-A (Registration of Human Gene Transfer Experiments) and information on completing and submitting the forms. |
| Ergonomic Forms | |
|---|---|
| Form | Description |
| Computer Self-Inspection Check List | To perform a self-inspection of your workstation refer to the section "Computer Workstation Ergonomics" of your Workplace Safety Employee Handbook. If possible, make appropriate adjustments to your workstation, for each "No" answer as you perform the inspection. If additional assistance is needed, please check the HSO follow-up requested column. |
| Industrial Hygiene Forms | |
|---|---|
| Form | Description |
| Asbestos Inspection Request Form | UNC-CH Architectural & Engineering Services Asbestos Inspection Request Form |
| Indoor Air Quality Investigation | Complete the "Request for Indoor Air Quality Investigation" if you would like EHS to make an initial assessment of indoor air quality in your workplace |
| IAQ - Evaluation of Illness Believed Related to Indoor Air Quality at Work | Refer to the UNC Indoor Air Quality Policy, page 5, under "Employees with Continuing IAQ Complaints" for the proper use of this form. |
| IAQ Diary | Save this spreadsheet to your computer and fill it out over the month. When it is complete, send the file to John Murphy. |
| Lead-Containing Paint Inspection Request Form | UNC-CH Architectural & Engineering Services Lead-Containing Paint Inspection Request Form |
| MSDS Request Form | Material Safety Data Sheet (MSDS) Request Form |
| Recurring Odor Complaint | Recurring odor complaint form |
| Request for Medical Consultation or Examination | Complete if you believe you have been over-exposed to a hazardous substance in the lab, or if you develop signs and symptoms associated with exposure to a hazardous substance. |
| Request for Monitoring | Request for monitoring exposures to chemicals in the workplace. |
| Safety Clearance Form | Safety Clearance Form for laboratory equipment that is to be repaired or moved, or laboratory facilities that have been vacated. For surplus property, use the self-adhesive orange labels available from EHS. |
| Laboratory Safety Forms | |
|---|---|
| Form | Description |
| Laboratory Safety Plan | NEW On-Line Laboratory Safety Plan |
| Laboratory Safety Plan Dates | Online lookup of date of most recent Laboratory Safety Plan submitted to EHS. Plan is to be updated at least once a year. |
| IBC Registration Forms | Schedule G (Registration of Recombinant DNA Experiments), Schedule H (Use of Transgenic Animals or Plants), and Appendix 10-A (Registration of Human Gene Transfer Experiments) and information on completing and submitting the forms. |
| Instructions for Laboratory Worker Registration Form | All laboratory personnel are required to register with EHS. Read instructions then complete on-line registration form. |
| Laboratory Worker Registration Form | On-Line Lab / Radiation Worker Registration Form |
| LSM Appendix 5-B | Glove selection chart. |
| LSP Annual Training and Documentation Form (Version 1) | Provide and document initial and annual training to laboratory personnel on the contents of the Chemical Hygiene Plan. (One employee version) |
| LSP Annual Training and Documentation Form (Version 2) | Provide and document initial and annual training to laboratory personnel on the contents of the Chemical Hygiene Plan. (Fifteen employee version) |
| Laboratory Closeout Procedure | This form is to guide laboratory personnel when laboratory operations are moved or discontinued. Other requirements may apply. |
| MSDS Request Form | Material Safety Data Sheet (MSDS) Request Form |
| Request for Monitoring | Request for monitoring exposures to chemicals in the workplace. |
| Request for Medical Consultation or Examination | Complete if you believe you have been over-exposed to a hazardous substance in the lab, or if you develop signs and symptoms associated with exposure to a hazardous substance. |
| Research Animal Handlers Questionnaire | Form for laboratory workers that handle research animals. Complete and send to UEOHC, CB # 1649. |
| Revisions to Laboratory Safety Manual | In order to keep the contents of the Laboratory Safety Manual up-to-date with current regulations and best practices, EHS may periodically rewrite, add, or delete sections. |
| Safety Clearance Form | Safety Clearance Form for laboratory equipment that is to be repaired or moved, or laboratory facilities that have been vacated. For surplus property, use the self-adhesive orange labels available from EHS. |
| Self-Audit Form | The items on this checklist are some of the most frequent causes of preventable laboratory accidents, and frequently cited by EHS during lab inspections. Contact EHS with any special concerns that arise from these self-audits, and repeat audits frequently in order to track whether your lab is making improvements. |
| Radiation Safety Forms | |
|---|---|
| Form | Description |
| Radiation Safety Manual | Radiation Safety Manual for Authorized Users and Radiation Workers |
| Appendix B | Lab/Radiation Worker Registration Form (Use electronic version if possible.) |
| Appendix C | Certification of Current Inventory for Purchase of Radiation Sources |
| Appendix D (Daily Inventory Log) | Authorized User's Radioactive Materials Inventory Record, EHS Forms 501 |
| Appendix F (Safety Clearance Form) | Safety Clearance Form for laboratory equipment that is to be repaired or moved, or laboratory facilities that have been vacated. For surplus property, use the self-adhesive orange labels available from EHS. |
| Appendix H | Contamination Survey Procedures |
| Appendix I | Radiation Safety Security Procedures |
| Human Use of Radiation in Research | Application for Human Use of Radiation in Research |
| Laboratory Closeout Procedure | This form is to guide laboratory personnel when laboratory operations are moved or discontinued. Other requirements may apply. |
| Laboratory Safety Plan | Laboratory Safety Plan: Includes Schedule C: Radioactive Materials; Schedule D: X-Ray Equipment; Schedule E: Lasers |
| Instructions for Laboratory Worker Registration Form | All laboratory personnel are required to register with EHS. Read instructions then complete on-line registration form. |
| Laboratory Worker Registration Form | NEW On-Line Lab/Radiation Worker Registration Form |
| Notice to Employees | This North Carolina Radiation Protection Section's form (in 8.5" X 14" format) must also be posted in each room authorized for the use of radioactive materials. |
| Postings | Pages 11, 20, and Appendix I of the Radiation Safety Manual (in 11" X 17" format) which must be posted in each room authorized for the use of radioactive materials |
| Radionuclide Characteristics | Characteristics of Commonly Used Radionuclides |
| Vacating Lab Space | Procedure for Vacating/Moving Laboratory Space |
| UEOHC Forms | |
|---|---|
| Form | Description |
| IAQ - Evaluation of Illness Believed Related to Indoor Air Quality at Work | Refer to the UNC Indoor Air Quality Policy, page 5, under "Employees with Continuing IAQ Complaints" for the proper use of this form. |
| Research Animal Handlers Questionnaire | Form for laboratory workers that handle research animals. Complete and send to UEOHC, CB # 1649. |
| Workers' Compensation Forms | |
|---|---|
| Form | Description |
| Employee Accident Report Form | This form is to be completed by the employee and forwarded to EHS as soon as practicable after the injury. |
| Supervisor Accident Report Form | This form is to be completed by the Supervisor and forwarded to EHS along with a copy of the NCIC Form 19 as soon as practicable. All incidents involving serious bodily injury or death must be reported to EHS immediately. |
| NCIC Form 19 | North Carolina Industrial Commission's Form 19. Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission. |
| Form 18 | Notice of Accident to Employer and Claim of Employee, Representative, or Dependent for Workers' Compensation Benefits |
