4. Principal Investigator/Project Leader

ETA Project Safety Review

Instructions: Complete this Project Safety Review (PSR) form for all continuing and proposed projects in addition to the NEPA/CEQA forms. For questions regarding this form, contact the ETA Safety Manager, Ron Scholtz X8137 or .

1. Date:

2. Project Name:

3. ETA Proposal Number:

4. Principal Investigator/Project Leader:

5. Expected Project Start Date:

6. Expected Project End Date:

7. Project Location (Check all that apply)

LBNL OfficeAreas

LBNL Lab Area

Building and Room Number:

Off-Site

Locations:

Meetings/Training/Tours Only

Hands-On Fieldwork.

Note: A “Fieldwork Hazard Assessment” form must be completed for all hands-on fieldwork conducted off-site. Go to the following link for a copy of the form:

Work Managed by Off-Site Facility Only. Give Details:

8. Project Staff (Check all that apply)

Current ETA Staff

Note: Ensure that all hazards, controls and training are addressed in the Activity Manager system. Ensure that all Work Activities are updated and approved as needed. Activity Manager link:

New Staff, Affiliates, Postdocs, or GSRA’s

Note: All new personnel will need to be assigned to the appropriate Work Activity and obtain a training profile. Notify the appropriate Activity Lead for assignment. Activity Managerlink:

Other Non-LBNL Personnel. Describe:

9. Use of Subcontractors under direction of LBNL

No subcontractors will be used.

Yes, subcontractorswill be used. Name all used.

Subcontractor Company Name(s):

Describe Work Being Performed:

Note: A Subcontractor JHA (SJHA) is required for any subcontractors that perform “hands-on” work. The SJHA system can be accessed by going to the following link:

10. New Equipment

No new equipment will be purchased, rented, or borrowed

Yes, new equipment will be purchased, rented, or borrowed.

Note: New equipment mustmeet LBNL standards including Nationally Recognized Testing Lab (NRTL) certification for items >50 volts. Go to the following link for the ETA New Equipment/Chemical Review Form:

11. Hazardous Materials

No hazardous materials or gases are used in this project

Yes, hazardous materials or gases are used in this project.

Name hazardous materials or gases used:

Note: Go to the following link for the ETA New Equipment/Chemical Review Form for any new equipment or chemicals:

12. Customer Environmental Surveys and Questionnaires

Does this project require submittal of a completed customer environmental questionnaire? If yes, submit for the questionnaire to the ETA Safety Manager for review.

13. Additional Comments:

PI/Project Leader Signature and Date: ______

Date

**************************************************************************************

14. ETA Safety Manager Comments and Recommendations:

ETA Safety Manager Signature and Date: ______

Date

Rev C (7/14/15)