The Occupational Safety and Health Administration (OSHA) requires that laboratory employees be made aware of the Chemical Hygiene Plan at their place of employment (29 CFR 1910.1450).

After reading the "Department of Natural Sciences, University of St. Francis, Chemical Hygiene Plan and Hazardous Material Safety Manual," please complete and return a copy of this form to your supervisor or to the Chemical Hygiene Officer. By signing below you acknowledge that you are aware of the Chemical Hygiene Plan and the policies and procedures applicable to the OSHA standard (29 CFR 1910.1450). Your supervisor will provide additional information and training as appropriate.

Please type or print legibly.

Name: _______________________________	Work Phone:______________
Staff or Student ID number: ______________________________________________
Department ________________________________________________________
Job Classification (if employee): ___________________________________
Building: _______________________________	Room: ___________________
Supervisor, instructor, or P.I. for your area: _____________________________
Signature:  _____________________________________  Date:________________

Completed Chemical Hygiene Plan Awareness Certifications are to be filed in a central administrative location within the staff member’s department. These and all safety training records should be organized in a way that allows original records to be retrieved quickly and efficiently on request by an OSHA inspector or a REM staff member, and to be retrieved for a single staff member or for an entire work group (identified by supervisor).

Received: ___________

Initials: _____________

Lab Safety Inventory

	Laboratory: ____________________		Date: ___________________
	Inspected by ___________________
___	Fire extinguisher	___	Safety shower and eyewash
___	Fire blanket	___	Splash-proof goggles***
___	Fire alarm	___	Specialty goggles U.V., IR, Laser, etc.
___	Dust pan and broom***	___	Face shield (8" minimum)
___	Respirators with appropriate cartridges*	___	Gloves appropriate for material(s) being used.
___	Acid/corrosive storage cabinet	___	Lab coat***
___	Bottle carrier(s) (rubber, polyethylene)	___	Dust masks
___	Hazard Assessments documented and posted	___	Other PPE (list)
___	Flammable storage cabinets	___	Safety cans for chemical storage
___	Spill control trays	___	Hearing protection (i.e., ear plugs)
___ ___ ___ ___ ___ ___	Spill clean-up media for: Acid Base Solvent Oil Mercury Radioactivity	___ ___ ___	Emergency procedures for: Fire*** Tornado*** Chemical spill or explosion***
___ ___ ___	Biosafety supplies: a. Sharps containers b. Autoclave bags c. Biohazard warning labels	___ ___	Laboratory hoods (fan operational, adequate face velocity, no broken glass, clean and orderly) Hood flow rate
___	Security locks for doors & windows	___	Natural Gas Shutoff
___	First Aid Supplies	___	Gas Cylinders Secured
___	Chemical Hygiene Plan***	___	Standard Operating Procedures***
___	Material Safety Data Sheets	___	Labeled Containers***

*** required in all laboratories that use hazardous chemicals

Laboratory Safety Training Form

Name: __________________________________________ Date: _____________________

Staff or Student ID Number ______________________ Department: ___________________

Job Classification: _________________________________ Room: ____________________

Supervisor, instructor, or P.I. for your area: _______________________________________

Training Received:

Instructors or supervisors should initial safety training they supervised or taught.

1. Introductory Safety Lecture by ____________________ on _____________.

2. Videos viewed:

_________-- Safety in Science Laboratory, EME Corp.

_________-- V7201 : Oxidation Hazards - More Than Just Air, ACS

_________-- V7301 : Out of Harms way - Safe Handling of Corrosive Chemicals, ACS

_________-- V7401 : Stop That Dose - Working Safely with Toxic Chemicals, ACS

_________-- V7601 : Taking the Long View - Carcinogens and Related Health Hazards, ACS

3. Fire extinguisher training was received on _______________.

4. Reviewed the Department of Natural Sciences Chemical Hygiene Plan on ____________.

Signature of employee: _______________________________________________________

Signature of supervisor: ______________________________________________________

Received by Department Chair: ________________