Laboratory Access Request Form

CAS Lab Support

3101 Science Circle CPISB 102A

Anchorage, AK 99508

Laboratory Access Request Form

Name: ______Date: ______

Status (Check all that apply):

Adjunct Instructor / Student (Grad)
Faculty / (Under Grad)
Post Doc / (High School)
Staff/Employee / Minor (Under 18)
Visitor / Other

Requested Building (s) Access: ______Room (s): ______

Starting Date: ______Ending Date: ______

Days M-F: ______Sat-Sun: ______Holidays/Closures: ______

Hours: Normal (7 am – 8 pm): ______Late (8 pm – 7 am): ______

The following section regarding General Safety and the next page concerning previous coursework, training sessions, documentation (listing) of specialized equipment and of all specialized lab protocols that will be used by person(s) requesting access must be completed prior to the granting of lab access.

General Safety Requirements Date Completed

Read UAA Chemical Hygiene Plan (Annually) ______

Read of UAA Lab Research Policies ______

Completion of Online Lab Safety Training (when available) ______

Review of Building Specific Emergency Procedures (Provided in Lab) ______

Development of Lab Specific Emergency Procedures (in Lab) ______

I acknowledge that I will not work alone in any lab w/o a written emergency procedures plan in place.

(Applicant sign here) ______

Signature of Supervisor/PI: ______Date: ______

Date Access was granted. ______Signature of CAS Lab Manager. ______

List of Previous Course Work and Training Sessions

To be completed by Individual

(Example: Previous Labs, ASET, other Universities or Employers)

______

______

______

______Attach Student Training Form______

______

______

______

List of Specialized Equipment to be Used

To be completed by Supervisor (PI)

(Example: Autoclave, Centrifuge, Gas Cylinders, etc.)

______

______

______

______Attach Equipment SOP Form ______

______

______

______

List of Specialized Protocols

To be completed by Supervisor (PI)

(Example: Radiation, Animal Research, Blood borne Pathogens, Cryogens, Lasers, Biohazards / Special Hazard Categories, Other)

______

______

______

______Attach Research Proposal SOP’s______

______

______

______

Hazardous Operations in Lab that cannot be done w/out direct supervision.

To be completed by Supervisor (PI)

______

______

______

______

______

______

______

Signature of Individual ______Date ______

Signature of Supervisor/PI ______Date______

These forms will be kept on file and updated as necessary or required by law.

Created by Maury Ringer, UAA CHO May 6, 2010

Fax: (907) -786-1267

Phone: (907) -786-1279

Formatted by Doug (Molby) Markussen August 12, 2010