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Forms

Application Note: Documents in DOC(x) format require Microsoft Word®.  Documents in PDF format require the Adobe Acrobat Reader®.  If you experience problems with PDF documents, please download the latest version of the Reader®.

Document Name / Description Last Revised
2016 Chemical and Agent Inventory Packet 12/15/2016
Table 1 – Chemicals of Interest 2016 01/05/2017
Aerial Lift / Scissor Lift Field Training Form 06/09/2006
Aerial Lift / Scissor Lift Self-Audit Checklist 04/07/2009
Bloodborne Pathogen Annual Self Assessment Worksheet 10/08/2013
Bloodborne Pathogen Exposure Control Assessment
This form is used to tailor your department’s Bloodborne Pathogens Exposure Control Plan.
08/30/2009
Bloodborne Pathogen Hepatitis B Vaccination Declination Form 07/22/2013
Bloodborne Pathogen Sharps Injury Log 08/30/2009
Bump Check Log
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 12/10/2010
Chemical Hygiene Plan – Lab Safety Training Checklist N/A
Chemical Spills (See Minor Chemical Spill Record) N/A
Chemical Waste Pickup and Disposal Request

Chemical and Waste Hazard Determination (instructions for the characteristics of hazardous waste

Chemical Hazardous (Spent Waste) Determination Form

10/24/201712/13/2017
Chemical Reuse Form
For chemicals or products which are suitable for redistribution to other departments.
01/28/2005
Competent Person Certification Record 06/09/2006
Computer Workstation Checklist
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
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 09/25/2004
Confined Space Evaluation Form 11/11/2011
Confined Space Self-Audit Checklist 04/13/2009
Continuity of Operations Plan (COOP) – Sample (also see Continuity of Operations Plan FAQ) 05/01/2009
Cranes and Hoists Daily Inspection 01/07/2005
Cranes and Hoists Monthly Inspection 01/07/2005
Cranes, Hoists, and Slings Self-Audit Checklist 04/07/2009
Department Annual Safety Training Checklist
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.
08/11/2017
Energized Electrical Work Permit 01/31/2007
Emergency Action Plan Survey
This form will assist you in developing your Emergency Action Plan.
09/19/2003
Emergency Call Card Form & Instructions
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 11/16/2016
Facility Emergency Coordinators Incident Report 12/05/2014
Fall Arrest Harness Training Form 05/10/2006
Field Research Hazard Assessment/Safety Plan 10/28/2014
General Area Safety Checklist 03/08/2013
HAZCOM Self-Audit Checklist 03/07/2013
HAZCOM Training Checklist 01/26/2017
HAZCOM Training – Supervisor’s Lesson Plan 10/03/2013
Hot Work Permit
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. 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 11/22/2017
Lab Cleanout Checklist 02/12/2008
Ladder Inspection Checklist – For portable step ladders. 03/05/2013
Lockout / Tagout Self Audit Form 10/01/2012
Machine Shop Safety Checklist 08/21/2017
Medical Testing – Pre-Employment Health and Safety Checklist
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 document for directions to help you fill out the form.
06/28/2013
Medical Testing – Supplemental Health and Safety Checklist
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 01/09/2009
Oil Spill/Leak Report Form FM
Personal Protective Equipment Assessment/Certification 09/10/2003
Pesticide Workers’ Checklist 09/28/2010
Pesticide Workers’ Training Checklist 07/28/2008
Powered Industrial Truck Operator Evaluation 04/27/2005
Powered Industrial Truck Operator Training Certification 11/20/2003
Powered Industrial Truck Pre-use Checklist 04/20/2005
Powered Industrial Truck Self-Audit Checklist 03/27/2013
Pre-Startup Checklist for New Installations or Alterations 09/05/2008
Radiation: Authorized Isotope User Application 12/31/2009
Radiation: Ionizing Radiation Producing Equipment Registration 12/31/2009
Radiation: Isotope Receipt Form 12/31/2009
Radiation: Personal Dosimeter Application 11/01/2010
Radiation: Radioisotope Receipt Utilization and Disposal Record 06/03/2013
Radiation: Request for Radioactive Waste Pick-up 12/31/2009
Radiation: Sealed Source Registration 12/31/2009
Radiation: Survey Meter Registration 12/30/2010
Radiation: Wipe Testing Procedure 07/31/2009
Respirator Medical Evaluation Questionnaire (Cutler Health) 11/28/2012
Respiratory Protection Voluntary Use Form 11/28/2012
Respiratory Protection Voluntary Use Form (for H1N1 Virus) 05/01/2009
Satellite Accumulation Area Self-Audit Checklist 01/16/2014
Satellite Accumulation Area Inspection Log 01/16/2014
Small Quantity Generator Central Accumulation Area Monthly Checklist 01/03/2018
Theatre Production Management of Change Approval Sheet 04/07/2009
Theatre Production Process Design Review Sheet 04/07/2009
Tier I – Investigation Report Form
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.
05/06/2015
Toxic Substances Control Act (TSCA) Research Exempt Substance Notification 04/01/2009
Training Record for Specialized Safety Training 07/17/2006
Training Requirements Checklist 04/01/2007
Training Roster 04/10/2017
Transportation and Parking Change Review 08/24/2012
Trenching and Excavation Inspection Log 08/01/2008
Trenching and Excavation Notification Form 07/05/2012
Trenching and Excavation Safety Checklist 08/01/2008
Universal Waste Inspection Checklist 02/17/2016
Universal Waste Storage Area Inspection Log 03/02/2004
Universal Waste Storage Area Inspection Log (Remote SQG Sites) 01/17/2011