FORMS INDEX
S06.01
Revised 7-09
Procedures, Records, and Forms
335-2005
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: S90.65.6 | |
| Application to Use Radiation Machines/ WSU1401/ 3-02 |
To request approval to use radiation machines. | PDF: S90.20.13-14 | |
| Application to Use Radioactive Materials/ WSU 1157/ 3-02 |
To request approval to use radioactive materials. | PDF: S90.20.6-11 | |
| Chemical Collection Request/ WSU 1280/ 10-94 |
For proper disposal or recycling of chemical substances. | Paper: CS Item #47860, Environmental Health and Safety's Environmental Services web site |
|
| 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: S30.60.4-5 | |
| 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 S35.10.22 | |
| 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 S35.10.23 | |
| Hazard Notification/ WSU 1247/ 1-09 |
To report safety hazards or unsafe practices. | PDF: S20.15.2 | |
| 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 | |
| Laboratory Survey/ WSU1406/ 3-02 |
To record the survey of an area where radioactive materials are used and stored. | PDF: S90.60.8 | |
| Material Safety Data Sheet (MSDS) Request/ WSU 1391/ 4-09 |
To request an MSDS for each hazardous chemical in the workplace. | PDF: S80.60.5 | |
| Notification of Change in Responsibility for a Radiation Machine/ WSU1407/ 3-02 |
To document the sale or transfer of a radiation machine. | PDF S90.25.16 | |
| Physician's Report/ WSU 1344/ 9-98 |
To provide a record of a physician's appraisal of an injured/ill employee's physical capabilities. | PDF: S25.30.3 | |
| Prenatal Radiation Exposure Statement/ WSU1408/ 3-02 |
To verify that female employees who experience occupational radiation exposure are aware of risks. | PDF: S90.75.16 | |
| Radiation Exposure History Release/ WSU1410/ 3-02 |
To request an employee's exposure history prior to WSU employment. | PDF: S90.65.7 | |
| 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: S90.25.17 | |
| Radiation Machine Registration/ WSU1402/ 3-02 |
To document the location, operating characteristics, and security measures for a radiation machine. | PDF S90.20.15 | |
| Radioactive Delivery Record/ WSU1411/ 3-02 |
To provide a record of the receipt, inspection, and surveying of incoming radioactive materials. | PDF: S90.30.6 | |
| Radioactive Materials Incident and/or Accident Report/ WSU1412/ 3-02 |
To document an accident or incident involving radioactive materials. | PDF: S90.55.7 | |
| Radioactive Sanitary Sewer Discharge Record/ WSU1413/ 3-02 |
To document the discharge of radioactive materials into the sewer system. | PDF: S90.80.8 | |
| Radioactive Waste Receipt/ 10-00 | To document disposal of radioactive wastes. | Paper: Radiation Safety Office | |
| 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: S90.20.12 | |
| 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 | |
| Safety Inspection Checklist/ WSU 1250/ 10-07 |
To conduct self inspection of department/ work area and document findings and corrective actions. | PDF: S20.50.3-12 | |
| Safety Meeting Report/ WSU 1248/ 8-97 |
To document safety committee or foreman- crew meetings. | PDF: S20.20.3 | |
| Safety Orientation Checklist/ WSU 1249/ 8-97 |
To document review of safety procedures. | PDF: S20.30.2 | |
| Summary of Radionuclide Disposals to the Air/ WSU1415/ 3-02 |
To document the discharge of radioactive materials to the air. | PDF: S90.80.9 | |
| Supervisor's Accident Investigation Report/ WSU 1246/ 8-97 |
To document an accident investigation. | PDF: S25.25.5 | |
| Witness or Injured Person Statement/ WSU 1315/ 8-97 |
To record a description of an accident. | PDF: S25.25.6 | |