To complete this form electronically please follow this link WORD CHECKLIST
| Surname:
|
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| Forename(s): |
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| Supervisor: |
| Title
of project / experiment: |
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| Location(s) of activity: |
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| Starting date: |
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| Proposed finishing date: |
| Brief
description of project / experiment: |
| Hazardous
substances Are chemicals / substances hazardous to health to be used? (e.g. irritants, toxins, flammables etc.) If YES, please list chemicals / substances to be used: |
YES
|
NO |
| Biological
substances Are biological substances to be used? If YES, please list biological substances to be used: |
YES |
NO |
| Work
with animals / invertebrates Does the project involve working with animals or invertebrates? If YES, please list animals or invertebrates to be used: |
YES |
NO |
| Electricity
Will the use or construction of any equipment expose the user / builder to voltages greater than 30v? |
YES |
NO |
| Radiation
Are radiation sources to be used (e.g. laser, alpha particle sources)? |
YES |
NO |
| Other
hazards Are any of the following to be used? robotic equipment power tools hand-held tools Does the project involve: lifting of heavy or bulky items? soldering? working at height? |
YES
YES YES YES YES YES |
NO
NO NO NO
NO NO |
|
If there are any
other activities
that you will be carrying out as part of this project that you think
are
potentially hazardous or that you have safety concerns about please
list below:
|
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