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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.
Adobe Reader Download

Feedback and/or Questions Web Submission Form


Animal Handling Risk Assessment

Physical Hazard Questionnaire

PDF File


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 Exposure Occupational Health Program:
Participation/Declination Form

PDF File
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
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
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
PDF File
Report These Materials (Reportable Materials)
PDF File
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


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

     Template: Modify the information to fit your laboratory.

Microsoft Word Document

     Template: Online Utility (use text boxes to enter information)
     This template was created by the Department of Chemistry.  If you
     have questions about its functionality contact Linda Swihart at
     49-47063 or swihart@purdue.edu.

Web Utility


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
Microsoft Word Document

Principal Investigator Letter of Certification (HMM-005)

PDF File


Integrated Safety Plan

Self-Audit Checklist

PDF File


Laser Safety

Laser Facility Approval Request (LF-1) - Editable Microsoft Word Document
Laser Project Application (LU-1) - Editable Microsoft Word Document
Laser Registration (LS-1) - Editable Microsoft Word Document
Laser User Application (LU-2) - Editable Microsoft Word Document


Occupational 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


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 R-1: Radioactive Material Requisition - (Attach to Radioactive Material Orders)

Microsoft Word Form

Form SM-1: Survey Meter Registration

Microsoft Word Form
Isotope Use Record Sheet
PDF File
NRC Form 3: Notice to Employees
PDF File
Radioactive Material Survey Record
PDF File
Radioactive Waste Disposal Poster
PDF File
Radioactive Waste Log Sheet
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

 

Copyright © 2006, Purdue University, all rights reserved.
Last Modified: Monday, September 21, 2009
Send questions or comments about this web site to judah@purdue.edu.

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