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Forms

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Document Name / Description Last Revised
Aerial Lift / Scissor Lift Field Training Form (PDF – 123 KB) 06/09/2006
Aerial Lift / Scissor Lift Self-Audit Checklist (PDF – 57 KB) 04/07/2009
Bloodborne Pathogen Annual Self Assessment Worksheet (PDF – 124 KB) 10/08/2013
Bloodborne Pathogen Exposure Control Assessment (PDF – 98 KB)
This form is used to tailor your department’s Bloodborne Pathogens Exposure Control Plan.
08/30/2009
Bloodborne Pathogen Hepatitis B Vaccination Declination Form (PDF – 102 KB) 07/22/2013
Bloodborne Pathogen Sharps Injury Log (PDF – 41 KB) 08/30/2009
Bump Check Log (PDF – 106 KB)
Use this form to “bump check” (field test) the MSA Orion Multigas Confined Space Meter.
07/16/2009
Chemical Hygiene Plan Certification and Annual Review (PDF – 111 KB) 12/10/2010
Chemical Hygiene Plan – Lab Safety Training checklist N/A
Chemical Spills (See Minor Chemical Spill Record) N/A
Chemical Pickup Form (PDF – 123 KB) (DOC – 66 KB) 07/21/2004
Chemical Reuse Form (PDF – 82 KB)
For chemicals or products which are suitable for redistribution to other departments.
01/28/2005
Competent Person Certification Record (DOC – 49 KB) 06/09/2006
Computer Workstation Checklist (PDF – 115 KB)
This checklist is used by the employee after they have completed the required annual training. It may also be used to conduct an evaluation of your own workstation.
03/08/2007
Confined Space Emergency/Rescue Services Notification (PDF – 74 KB)
Use this to ensure that rescue services are available to UMaine employees working in permit-required confined spaces.
10/23/2009
Confined Space Entry Permit (PDF – 176 KB) 09/25/2004
Confined Space Evaluation Form (DOC – 76 KB) 11/11/2011
Confined Space Self-Audit Checklist (PDF – 70 KB) 04/13/2009
Continuity of Operations Plan (COOP) – Sample (DOC – 168 KB) (also see Continuity of Operations Plan FAQ (PDF – 156 KB)) 05/01/2009
Cranes and Hoists Daily Inspection (PDF – 98 KB) 01/07/2005
Cranes and Hoists Monthly Inspection (PDF – 102 KB) 01/07/2005
Cranes, Hoists, and Slings Self-Audit Checklist (PDF – 61 KB) 04/07/2009
Department Annual Safety Training Checklist (DOC – 102 KB)
The area supervisor or their designee must conduct the required training on the following items listed on this checklist on an annual basis. This checklist may also be used by the supervisor as documentation of training.
04/24/2007
Energized Electrical Work Permit (DOC – 94 KB) 01/31/2007
Emergency Action Plan Survey (DOC – 49 KB)
This form will assist you in developing your Emergency Action Plan.
09/19/2003
Emergency Call Card Form & Instructions (DOC – 33 KB)
Two cards. One card is filled out and returned to SEM with your inventory, and one is posted on the door of your chemical use, or storage area.
01/04/2005
Event Manager Security/Safety Planning Form (DOCX – 32 KB) 11/30/2012
Facility Emergency Coordinators Incident Report (DOC – 89 KB) 09/28/2012
Fall Arrest Harness Training Form (PDF – 94 KB) 05/10/2006
Field Research Hazard Assessement/Safety Plan (PDF – 139 KB) 10/28/2014
General Area Safety Checklist (PDF – 88 KB) 03/08/2013
Hazardous Waste Determination Request Form (PDF – 356 KB) 04/18/2008
HAZCOM Self-Audit Checklist (PDF – 61 KB) 03/07/2013
HAZCOM Training Checklist (PDF - 84 KB) 10/03/2013
HAZCOM Training – Supervisor’s Lesson Plan (PDF – 376 KB) 10/03/2013
Hot Work Permit (PDF – 93 KB)
A Hot Work Permit must be completed prior to welding, cutting, or brazing operations that occur outside of a designated welding area as described in the UMaine Welding, Cutting and Brazing Policy (PDF – 143 KB). Hot Work Permits are also required when welding, cutting, or brazing operations are conducted on used pipes, drums, tanks, barrels, or other containers.
11/20/2013
Incident Report Form
For reporting property damage or injuries to visitors, students, or general public. Do not use this form for employee injuries. 
N/A
Injury/Illness Report Form
For reporting all work related employee injuries/illnesses whether they result in medical attention or not.
N/A
Lab Safety Checklist (PDF – 96 KB) 03/11/2013
Lab Cleanout Checklist (PDF – 57 KB) 02/12/2008
Ladder Inspection Checklist (PDF – 57 KB)
For portable step ladders.
03/05/2013
Lockout / Tagout Self Audit Form (PDF – 82 KB) 10/01/2012
Machine Shop Safety Checklist (PDF – 86 KB) 03/07/2005
Medical Testing – Pre-Employment Health and Safety Checklist (DOC – 94 KB)
This checklist is intended to determine and document what medical testing is required for an employee (classified by job title) during a post-offer, pre-employment physical. Download Human Resource’s/Safety and Environmental Management’s Guidance (PDF – 111 KB) document for directions to help you fill out the form.
06/28/2013
Medical Testing – Supplemental Health and Safety Checklist (DOC – 90 KB)
This checklist is intended to determine and document what medical testing is required for an employee (classified by job title) as the result of a change in the employees duties.
12/01/2008
Minor Chemical Spill Record (PDF – 209 KB) 01/09/2009
Oil Spill/Leak Report Form (PDF – 1.2 MB) FM
Personal Protective Equipment Assessment/Certification (PDF – 135 KB) 09/10/2003
Pesticide Workers’ Checklist (PDF – 86 KB) 09/28/2010
Pesticide Workers’ Training Checklist (PDF – 66 KB) 07/28/2008
Powered Industrial Truck Operator Evaluation (PDF – 82 KB) 04/27/2005
Powered Industrial Truck Operator Training Certification (PDF – 86 KB) 11/20/2003
Powered Industrial Truck Pre-use Checklist (PDF – 74 KB) 04/20/2005
Powered Industrial Truck Self-Audit Checklist (PDF – 74 KB) 03/27/2013
Pre-Startup Checklist for New Installations or Alterations (PDF – 143 KB) 09/05/2008
Radiation: Authorized Isotope User Application (DOC – 74 KB) 12/31/2009
Radiation: Ionizing Radiation Producing Equipment Registration (PDF – 53 KB) 12/31/2009
Radiation: Isotope Receipt Form (PDF – 74 KB) 12/31/2009
Radiation: Personal Dosimeter Application (PDF – 111 KB) 11/01/2010
Radiation: Radioisotope Receipt Utilization and Disposal Record (DOC – 114 KB) 06/03/2013
Radiation: Request for Radioactive Waste Pick-up (DOC – 49 KB) 12/31/2009
Radiation: Sealed Source Registration (PDF – 74 KB) 12/31/2009
Radiation: Survey Meter Registration (PDF – 94 KB) 12/30/2010
Radiation: Wipe Testing Procedure (PDF – 82 KB) 07/31/2009
Respirator Medical Evaluation Questionnaire (Cutler Health) (PDF – 47 KB) 11/28/2012
Respiratory Protection Voluntary Use Form (PDF – 69 KB) 11/28/2012
Respiratory Protection Voluntary Use Form (for H1N1 Virus) (PDF – 90 KB) 05/01/2009
Satellite Accumulation Area Self-Audit Checklist (PDF – 90 KB) 04/06/2007
Satellite Accumulation Area Inspection Log (PDF – 60 KB) 11/04/2004
Theatre Production Management of Change Approval Sheet (DOC – 61 KB) 04/07/2009
Theatre Production Process Design Review Sheet (DOC – 70 KB) 04/07/2009
Tier I – Investigation Report Form (DOC – 106 KB)
The purpose of this form is to provide a more detailed description of the incident. A thorough understanding of the task being performed; and identification of contributing conditions will help us to take appropriate corrective actions, thereby reducing risks.
08/17/2005
Toxic Substances Control Act (TSCA) Research Exempt Substance Notification (PDF – 49 KB) 04/01/2009
Training Record for Specialized Safety Training (PDF – 82 KB) 07/17/2006
Training Requirements Checklist (PDF – 115 KB) 04/01/2007
Training Roster (PDF – 53 KB) 03/06/2009
Transportation and Parking Change Review (DOC - 66 KB) 08/24/2012
Trenching and Excavation Inspection Log (PDF – 78 KB) 08/01/2008
Trenching and Excavation Notification Form (PDF – 75 KB) 07/05/2012
Trenching and Excavation Safety Checklist (PDF – 74 KB) 08/01/2008
Universal Waste Inspection Checklist (PDF – 70 KB) 04/06/2007
Universal Waste Storage Area Inspection Log (PDF – 106 KB) 03/02/2004
Universal Waste Storage Area Inspection Log (Remote SQG Sites) (PDF – 123 KB) 01/17/2011