Washington State University
SAFETY POLICIES AND PROCEDURES MANUAL

INTRODUCTION / ORGANIZATION
1.20
Revised 9-13
Procedures, Records, and Forms
335-2005

SPPM Forms Index

PDF link


Forms may be available in the following formats:


Title/Number/
Last Revised
Primary Purpose Where Available

SPPM Reference

Application for a Personnel Monitoring Device/
WSU1404/ 3-02
To request a radiation personnel monitoring device from the Radiation Safety Office. PDF: 9.45.6

9.45

Application to Use Radiation Machines/
WSU1401/ 3-02
To request approval to use radiation machines. PDF: 9.20.13-14

9.20

Application to Use Radioactive Materials/
WSU 1157/ 3-02
To request approval to use radioactive materials. PDF: 9.20.6-11

9.20

Chemical Collection Request/
WSU 1280/ 10-94
For proper disposal or recycling of chemical substances. Paper: US Item #47860,
Environmental Health and Safety's Environmental Services web site

5.66

Fall Protection Work Plan/ 10-92 To document actions taken to prevent falls. Required when working ten feet or more above the level below. PDF: 3.34.6-7

3.34

Full-Size Van Driver Safe Driving Practices Acknowledgment Statement/
WSU1426/ 7-09
To record driver acknowledgment of risks an recommended safe driving practices for operating a full-size van. PDF 7.10.22

7.10

Full-Size Van Driver Valid License to Drive and Driving Experience Statement/
WSU1427/ 7-09
To record manager/supervisor and full-size van driver acknowledgment of responsibilities prior to and during the driver's assignment to operate a full-size van. PDF 7.10.23

7.10

Hazard Notification/
WSU 1247/ 1-09
To report safety hazards or unsafe practices. PDF: 2.52.2

2.52

Incident Report/
WSU1131/ 1-08
To report accidental injury or work-related illness involving WSU employee or third party; may also be used for property damage. Online: Human Resource Services website

2.24

Laboratory Survey/
WSU1406/ 3-02
To record the survey of an area where radioactive materials are used and stored. PDF: 9.42.8

9.42

Material Safety Data Sheet (MSDS) Request/
WSU 1391/ 4-09
To request an MSDS for each hazardous chemical in the workplace. PDF: 5.10.5

5.10

Notification of Change in Responsibility for a Radiation Machine/
WSU1407/ 3-02
To document the sale or transfer of a radiation machine. PDF 9.22.16

9.22

Prenatal Radiation Exposure Statement/
WSU1408/ 3-02
To verify that female employees who experience occupational radiation exposure are aware of risks. PDF: 9.50.16

9.50

Public-Access Defibrillator Use Agreement/
WSU1477/ 12-09
To request approval to install and use an automated external defibrillator (AED) in a University location. PDF: 2.46.3

2.46

Radiation Exposure History Release/
WSU1410/ 3-02
To request an employee's exposure history prior to WSU employment. PDF: 9.45.7

9.45

Radiation Machine Reactivation Notice/ 3-02 Used to notify the RSO when an inactive radiation machine is put back into active service. Post on machine at time of surplus. PDF: 9.22.17

9.22

Radiation Machine Registration/
WSU1402/ 3-02
To document the location, operating characteristics, and security measures for a radiation machine. PDF 9.20.15

9.20

Radioactive Delivery Record/
WSU1411/ 3-02
To provide a record of the receipt, inspection, and surveying of incoming radioactive materials. PDF: 9.25.6

9.25

Radioactive Materials Incident and/or Accident Report/
WSU1412/ 3-02
To document an accident or incident involving radioactive materials. PDF: 9.35.7

9.35

Radioactive Sanitary Sewer Discharge Record/
WSU1413/ 3-02
To document the discharge of radioactive materials into the sewer system. PDF: 9.60.8

9.60

Radioactive Waste Receipt/ 10-00 To document disposal of radioactive wastes. Paper: Radiation Safety Office

9.60

Request for Reduction in Scope of Radioactive Material Use/
WSU1416/ 3-02
To request a simple change involving a reduction in scope of an existing authorization to use radioactive materials. PDF: 9.20.12

9.20

Respirator Authorization/Respirator Fit-Testing and Training Record/ 2-00 To authorize the use of respirators and provide a record of respirator fit-testing and respirator use training. Paper: Environmental Health and Safety

3.24

Safety Inspection Checklist/
WSU 1250/ 10-07
To conduct self inspection of department/ work area and document findings and corrective actions. PDF: 2.50.3-12

2.50

Safety Meeting Report and Agenda/
WSU 1248/ 10-11
To document safety committee or foreman- crew meetings. PDF: 2.12.4-5

2.12

Safety Orientation Checklist/
WSU 1249/ 1-13
To document review of safety procedures. PDF: 2.16.2

2.16

Summary of Radionuclide Disposals to the Air/
WSU1415/ 3-02
To document the discharge of radioactive materials to the air. PDF: 9.60.9

9.60

Supervisor's Accident Investigation Report/
WSU 1246/ 8-97
To document an accident investigation. PDF: 2.26.5

2.26

Witness or Injured Person Statement/
WSU 1315/ 9-13
To record a description of an accident. PDF: 2.26.6

2.26