REM Forms

Most of our forms are in pdf format. Please download Adobe Acrobat Reader if you do not have it installed on your computer.

Feedback and/or Questions

Web Submission Form

Biohazards/Environmental Health

Agent Inventory Form - for users of HEPA filtered cabinets	PDF File
	Microsoft Word Document
Animal Exposure Occupational Health Program: Participation/Declination Form	PDF File
Animal Exposure Occupational Health Program: Risk Assessment Form	PDF File
	Microsoft Word Document
Biological Safety Awareness Certification	PDF File
Bio-Materials Pickup & Treatment Certification Form	PDF File
Bloodborne Pathogens Exposure Control Plan Forms
Training and Information Certification	PDF File
Department Hepatitis B Vaccination Eligibility List	Microsoft Word Document
Hepatitis B Vaccination Declination	Microsoft Word Document
Authorization for Use, Disclosure, or Release of Protected Health Information and Medical Records This is not a REM form. If there are any questions concerning this form or the Health Insurance Portability and Accountability Act (HIPAA) email Joan Vaughan or call 61927.	Microsoft Word Document
DEA Controlled Substance Forms
Drug Enforcement Administration License Information Survey	Microsoft Word Document
Controlled Substance Physical Inventory (REMCS Form 1)	PDF File
Record of Controlled Substance Purchases (REMCS Form 2)	PDF FILE
Record of Controlled Substances Administered/Dispensed (REMCS Form 3)	PDF File
Record of DEA Form 222 Use (REMCS Form 4)	PDF File
Controlled Substance Authorized Users List (REMCS Form 5)	PDF File
Controlled Substance Program Security Release (REMCS Form 6)	PDF File
Foodborne Illness Forms
Foodborne Illness Report Form	Microsoft Word Document

Chemical Safety and Industrial Hygiene

MSDS Request Form (HCP-1)	PDF File
	Microsoft Word Document
	Email Submission Form
Chemical Hygiene Plan Awareness Certification	PDF File
Chemical Inventory Form (HCP-4)	PDF File
Chemical Inventory Form (HCP-4)	Microsoft Excel Document
Confined Space Forms
Confined Space Entry Permit (CS-1)	PDF File
Fire Department Confined Space Entry Data (CS-2)	PDF File
Non-Permit Confined Space Certification (CS-3)	PDF File
Permit Confined Space Entry - Contractor Debrief (CS-4)	PDF File
Employee Exposure Information (HCP-5)	PDF File
Employee Right-to-Know Attendance Record (HCP-8)	PDF File
Laboratory Door Posting	Microsoft Word Document
Laboratory Door Posting	PDF File
Report These Materials (Reportable Materials)	PDF File
Report These Materials (Reportable Materials)	Microsoft Word Document
Refrigerator/Freezer Poster - NO FLAMMABLES	PDF File
Refrigerator/Freezer Poster - FLAMMABLE SAFE & NO FOOD	PDF File
Refrigerator/Freezer Poster - NO FOOD	PDF File

General Safety

Building Emergency Plan Template		Microsoft Word Document
Energized Electrical Work Permit This is not a REM form. If there are any questions concerning this form or energized electrical work contact Dan Dunbar (Electric, Electronic and Elevator Foreman) , 44881 or John Biggs (Chairman, Electrical Safety Committee), 44637.		Microsoft Word Document
	Energized Electrical Work Permit Instructions This is not a REM document, see the above cell for contact information.	Microsoft Word Document
First Report of Injury Form - (Now for ALL Purdue Employees)		Microsoft Word Document
Form 113 - OSHA Compliance Funding Request (with attached guidelines and procedures)		Microsoft Word Document
LOCKOUT/TAGOUT PROGRAM Appendix D2: Equipment Lockout Work Plan		Microsoft Word Document
Office Worker Ergonomics Questionnaire		Web Submission Form
Physical Facilities Prescription Safety Glasses Authorization Form (Form 52)		PDF File

Hazard Assessment
and
Personal Protective Equipment (PPE) Policy

PPE Certification of Training	PDF File
Hazard Assessment Certifications (APPENDIX A)
APPENDIX A1 - Single Task (Editable Form)	Microsoft Word Document
APPENDIX A2 - Position/Title (Editable Form)	Microsoft Word Document
APPENDIX A3 - Location
Editable Form - blank form	Microsoft Word Document
Online Utility - use text boxes to enter information	Web Utility
Template - modify information to fit your laboratory	Microsoft Word Document

Hazard Clearance & Declaration Form

Hazard Clearance & Declaration Form (Clean Sheet) - This form is used to certify that equipment and spaces submitted for maintenance, moving, or repair have been cleaned or kept as clean as possible. In addition, this form also communicates precautions that must be taken by personnel that perform maintenance, moving, and repair work. See the Hazard Clearance and Declaration web page for information about the form including how and when it should be used as well as contact information.

PDF File

Hazardous Materials Management

Hazardous Material Pickup Request (HMM-001)
	Email Method Only: (Requires Acrobat Reader 8 or higher and installed email client software) Pressing the "Submit by Email" button opens your email client with the form attached to an email.	PDF Email Submission Form
	Web Submission Method: The web submission form is sent to REM when you click on the "Send" button located at the bottom of the page.	Web Submission Form
	Fax, Campus Mail, or Email Method: The Microsoft Word Document may be used as you wish.	Microsoft Word Document
Bio-Materials Pickup & Treatment Certification Form		PDF File
Bio-Materials Pickup & Treatment Certification Form		Microsoft Word Document
Principal Investigator Letter of Certification (HMM-005)
		PDF File

Integrated Safety Plan

Self-Audit Checklist	PDF File
Self-Audit Checklist - Editable Version	Microsoft Word Document

Laser Safety

Laser Facility Use Application (LU-1) - Editable	Microsoft Word Document
Laser System Registry (LS-1) - Editable	Microsoft Word Document
Laser Use Application (LU-2) - Editable	Microsoft Word Document

Radiation Safety

Radioactive Waste Pickup Request	PDF Email Submission Form
Form A-1: Project Summary & Evaluation for Use of Radioactive Materials and Radiation Producing Devices (New/Amend Project Form)	Microsoft Word Form
Form A1-S: Radiation Facility Approval Request (New Lab Application)	Microsoft Word Form
Form A-4: Application to Use Radioactive Materials and/or Radiation Producing Devices (New User Application)	Microsoft Word Form
Form F-1: Notice of Dosimetry Exposure	Microsoft Word Form
Form R-1: Radioactive Material Requisition - (Attach to Radioactive Material Orders)	Microsoft Word Form
Form SM-1: Survey Meter Registration	Microsoft Word Form
NRC Form 3: Notice to Employees	PDF File
Radioactive Waste Disposal Poster	PDF File

REM Intradepartmental Forms

ISP Certification Memo: This memo can be emailed to the intended recipients or printed by clicking the "Submit by Email" or "Print" button respectively. The buttons are located at the top or bottom of the page. You mal also saved it with or without information present in the fields.

Email Submission Form