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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:
April 11, 2014

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REM Forms

Environmental Health & Biological Safety
Form Name and Description Form Format
Biological Exposure
Agent Inventory - for users of HEPA filtered cabinets 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
Hazardous Material Shipment Request 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
CS-5: Confined Space Meter Calibration PDF
CS-6: Attended Permit Entry Confined Space Training 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
Indoor Air Quality Concern PDF
Laboratory Information Door Posting 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) - 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

President’s Safety Award Nomination

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
Electrical Safety
Hazard Assessment for Electrical Work & Energized Electrical Work Permit - Can be completed online. PDF
Hazard Risk Assessment - Can be completed online. This form will automatically calculate the Risk rating (R) based on input into the Frequency (F), Likelihood (L), and Severity (S) fields. PDF
Equipment Lockout Work Plan (Lockout/Tagout Program Appendix D2) Word Document
Excavation Safety
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) PDF Submission
Office Worker Ergonomics Questionnaire Web Submission
wert890-987654321`23Physical 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 Audit Memorandum/Checklist: 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. PDF Submission

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