/ London Centre for Nanotechnology
17-19 Gordon Street
London WC1H 0AH

Permit To Access Controlled Areas

This form is required to be completed to enable LCN access cards to be programmed for restricted laboratory access

Once completed this form must be returned to Denise Ottley – LCN Central Administration Level 5

Personal Details

Name
Supervisor
Lab Manager
Laboratory

Work Details(to be completed by LCN Supervisor/LCN Lab Manager)

Are all tasks to be undertaken by this person covered by an LCN Procedural Risk Assessment (PRA)? / YES / NO
If no, then a full PRA will need to be carried out.
Please enter the appropriate LCN PRA number(s) applicable to this application / CR09/01-05
CR10/01-02
Are there any special conditions associated with access by the person named above? / YES
If yes then list below. / NO
Special conditions:
Access Monday-Friday 09:00 to 18:00 (11C) / Access 24/7 (10C)
Countersign by Cleanroom Manager

Confirmation and declarations

LCN Lab Manager
I confirm that the person named in this application has been shown and has read all necessary Procedural Risk Assessments, LCN Handbook, Codes Of Practice and other health and safety documentation relevant to their work in the laboratory/office. I confirm that all work that the named person will be undertaking will be in compliance with LCN, UCL and Statutory health and safety requirements and that exposure to hazardous activities and materials is kept to an absolute minimum. I also confirm that full training on equipment and procedures will be provided where necessary.
Lab Manager Signature: / Date:
Print name: Stephen Etienne
LCN Supervisor
I confirm that the person named in this application has been shown and has read all necessary Procedural Risk Assessments, LCN Handbook, Codes Of Practice and other health and safety documentation relevant to their work in the laboratory/office. I confirm that all work that the named person will be undertaking will be in compliance with LCN, UCL and Statutory health and safety requirements and that exposure to hazardous activities and materials is kept to an absolute minimum. I also confirm that full training on equipment and procedures will be provided where necessary.
Supervisor Signature: / Date:
Print name:
LCN Facilities User
I confirm that I have been shown and have read, understood and agree to abide by all Procedural Risk Assessments, Codes Of Practice and other health and safety documentation relevant to my work in the laboratory/office. I agree to work in a safe manner in accordance with LCN, UCL and Statutory health and safety requirements and will keep exposure of myself and any colleagues to any hazardous activities or materials to an absolute minimum. I also agree to co-operate with my Principal Investigator/Manager and take part in any training requested.
Signature: / Date:
Print name:

London Centre For Nanotechnology – Access Form

Status: Live

Dr Kevin J Thurlow – December2009