|
|
Vertical Menu Bar
|
Vertical Menu Bar2
|
Contact Information
Radiological and
Environmental Management
550 Stadium Mall Drive
West Lafayette, IN 47907-2051
Information: (765) 49-46371
Fax: (765) 49-47403
Office Location: HAMP B173
Campus Mail: REM, HAMP
Page Updated:
May 3, 2013
To open PDF documents, you may need to download Adobe Acrobat Reader.
|
|
|
REM Forms
|
Environmental Health & Biological Safety
| Form Name and Description |
Form Format |
| Biological Exposure |
| Agent Inventory - for users of HEPA filtered cabinets |
PDF |
| Biological Exposure Occupational Health Program: Participation/Declination |
PDF |
| Biological Safety Awareness Certification |
PDF |
| Bio-Materials Pickup & Treatment Certification |
PDF |
| Bloodborne Pathogens Exposure Control Plan |
| Department Hepatitis B Vaccination Eligibility List |
PDF |
| Training and Information Certification |
PDF |
| DEA Controlled Substances |
| REMCS Form 1: Controlled Substance Physical Inventory |
PDF |
| REMCS Form 2: Record of Controlled Substance Purchases |
PDF |
| REMCS Form 3: Record of Controlled Substances Administered/Dispensed |
PDF |
| REMCS Form 4: Record of DEA Form 222 Use |
PDF |
| REMCS Form 5: Controlled Substance Authorized Users List |
PDF |
| REMCS Form 6: Controlled Substance Program Security Release |
PDF |
| Food Safety |
| Foodborne Illness Report Form |
PDF Submission |
| Temporary Food Service Application |
PDF Submission |
Hazardous Materials Management
| Form Name and Description |
Form Format |
| Hazardous Material Pickup Request (HMM-001) |
| The PDF version requires Acrobat Reader 8 or higher and an installed or internet email client. The "Submit by Email" button will allow you to choose the type of email client you want to use. |
PDF Submission |
| Web Submission |
| Fax, Campus Mail, or Email Method - The Word Document may be used as you wish. |
Word Document |
| Principal Investigator Letter of Certification (HMM-005) |
PDF |
| Request to Ship Hazardous Materials |
PDF |
Industrial Hygiene & Chemical Safety
| Form Name and Description |
Form Format |
| Chemical Hygiene Plan Awareness Certification |
PDF |
| Confined Space |
| CS-1: Confined Space Entry Permit |
PDF |
| CS-2: Fire Department Confined Space Entry Data |
PDF |
| CS-3: Non-Permit Confined Space Certification |
PDF |
| CS-4: Permit Confined Space Entry - Contractor Debrief |
PDF |
| Hazard Communication (Right to Know) |
| HCP-1: MSDS Request |
PDF |
| Web Submission |
| Word Document |
| HCP-4: Chemical Inventory |
PDF |
| XLS/XLSX |
| HCP-5: Employee Exposure Information |
PDF |
| HCP-8: Employee Right-to-Know Attendance Record |
PDF |
| Laboratory Door Posting |
Word Document |
| PDF |
| Report These Materials (Reportable Materials) |
Word Document |
| PDF |
| Refrigerator/Freezer Posting |
| NO FLAMMABLES |
PDF |
| FLAMMABLE SAFE & NO FOOD |
PDF |
| NO FOOD |
PDF |
| Respiratory Protection Program |
| RPP Form 1: Participation Application |
PDF |
| RPP Form 2: Training Record |
PDF |
| RPP Form 3: Information for Employees Using Respirators When Not Required Under the Standard (29 CFR 1910.134, Appendix D) |
PDF |
| RPP Form 4: Respirator Inspection Record |
PDF |
Injury
| Form Name and Description |
Form Format |
| First Report of Injury (FROI) Form - Effective July 1, 2010 a new "First Report of Injury" (FROI) form will take effect. For new guidelines and instructions on how to use the new form go to the First Report of Injury web page. |
FROI Form |
Laser Safety
| Form Name and Description |
Form Format |
| Laser Facility Approval Request (LF-1) - Editable |
Word Document |
| Laser Project Application (LU-1) - Editable |
Word Document |
| Laser Registration (LS-1) - Editable |
Word Document |
| Laser User Application (LU-2) - Editable |
Word Document |
Miscellaneous
| Form Name and Description |
Form Format |
| Feedback |
Web Submission |
| Hazard Clearance & Declaration (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 |
| Minors in Research Laboratories or Animal Facilities (includes Guidance Document) |
PDF |
| Self-Audit Checklist [Integrated Safety Plan (ISP)] |
PDF |
Occupational Safety
| Form Name and Description |
Form Format |
| Building Emergency Plan Template: This is not a REM from. The link provided takes you to the Emergency Preparedness web site's Building Emergency Plan (BEP) page where you can download the template and view a PowerPoint presentation on preparing your BEP. If you have any questions contact Ron Wright, Director Campus Emergency Preparedness and Planning, at (765) 49-40446 |
Link to BEP Web Page |
| 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, at (765) 49-44881 or Jon Biggs, Chairman, Electrical Safety Committee, at (765) 49-44637. (Instructions: Not a REM document, contact Dan Dunbar or Jon Biggs for more information.) |
Word Document |
| Equipment Lockout Work Plan (Lockout/Tagout Program
Appendix D2) |
Word Document |
| Excavation Work |
| Excavation Competent Person Evaluation (ET-1) |
PDF |
| Excavation Site Checklist and Daily Field Report (ET-2) |
PDF |
| Form 113 - OSHA Compliance Funding Request (with attached guidelines and procedures) |
Word Document |
| Office Worker Ergonomics Questionnaire |
Web Submission |
| Physical Facilities Prescription Safety Glasses Authorization Form (Form 52) |
PDF |
| Safety Training Sign In Sheet |
PDF |
Personal Protective Equipment (PPE) Policy
| Form Name and Description |
Form Format |
| Certification of Training |
PDF |
| Hazard Assessment Certification |
| Appendix A1 - Single Task (Editable Form) |
Word Document |
| Appendix A2 - Position/Title (Editable Form) |
Word Document |
| Appendix A3 - Location (Editable form) |
Word Document |
| Appendix A3 - Location (Template: Modify the information to fit your laboratory.) |
Word Document |
Radiation Safety
| Form Name and Description |
Form Format |
| Radioactive Waste Pickup Request |
PDF Submission |
| Form A-1: Project Summary & Evaluation for Use of Radioactive Materials and Radiation Producing Devices (New/Amend Project Form) |
Word Document |
| Form A1-S: Radiation Facility Approval Request (New Lab Application) |
Word Document |
| Form A-4: Application to Use Radioactive Materials and/or Radiation Producing Devices |
Word Document |
| Form A-5: Request to Access Gamma Irradiator |
PDF Submission |
| Form R-1: Radioactive Material Requisition - (Attach to Radioactive Material Orders) |
Word Document |
| Form SM-1: Survey Meter Registration |
Word Document |
| Isotope Use Record Sheet |
PDF |
| NRC Form 3: Notice to Employees |
PDF |
| Radioactive Material Survey Record |
PDF |
| Radioactive Waste Disposal Poster |
PDF |
| Radioactive Waste Log Sheet |
PDF |
REM Intradepartmental
| Form Name and Description |
Form Format |
| 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 may also save it with or without information present in the fields. |
Email Submission |
|
|
