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Electronic Forms
The following forms are available for completion on line. If you are not able complete the forms online, please email the Safety Office for a hard copy to be sent to you, or download the word/pdf versions.
DSE Checklist
Fire Report Form
Risk assessment for work involving open radioactive sources (RAD 5)
Hazard Report Form
Accident Report Form
Notices
First Aid Notice (showing defibrillator operators)
Standard forms
The following forms are available for completion on line (with the exception of the accident forms). Some of the forms are linked to html files or are in pdf format or in Microsoft Word. If you are not able to download Word documents, please email Safety Office for a hard copy to be sent to you.
If a form is not listed above, please contact the Safety Office by E-mailing the Safety Office or calling us on 0115-9513401 (13401 internally).
Audits
Annual Safety Report
Audit Checklists
Certificate of decontamination for laboratory equipment used with hazardous substances
Chemicals
Drugs Precursor Registration Form - on-line form to be available soon. Contact Safety Office (13401) for information.
Display Screen Equipment
Display Screen Workstation Checklist
Eye test form for Display Screen Equipment users
Fire
Fire Report Form
Personal Emergency Egress Plan (PEEP)
Genetic Modification
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Genetic Modification Risk Assessment for production and use of genetically modified micro-organisms. Revised Sept 2011
- Genetic Modification Risk Assessment for infection of animals with GMMs - Appendix A
- Genetic Modification Risk Assessment for the contained use of a genetically modified animal - Appendix B
- Genetic Modification Risk Assessment for Plants in containment
- Genetic Modification Risk Assessment amendment form
- Amendment form for Genetic Modification plants in containment
- Amendments form for addition of new GM animal strain. New Sept 2011
Lasers
Laser User Registration Form
Screening Questionnaire for Prospective Users of Class 3B or 4 Lasers
Laser Registration Form
Laser Survey Form
Manual Handling
Manual Handling Risk Assessment Form
Permits
Hot Work Permit
Hazardous areas - Entry by Contractors and Maintance Staff (permit to work form)
Radiation Protection
Radiation Protection Supervisor - notification of appointment
Registration form for individuals working with sources of radiation (amended April 2010)
Open radioactive sources - proposal for new work or to extend existing work (Rad 1)
Request for the acquisition of closed radioactive sources (Rad 2)
Proposal for the acquisition of x-ray generating equipment (Rad 3)
Request to decommission equipment containing a closed source (Rad 4)
Risk assessment for work involving open radioactive sources (Rad 5) HTML
Risk assessment for work with machine sources of radiation (Rad 6)
Radioactive Waste Transfer Note - Medical School Use Only
Annual Radiation Inspection Checklist
Dosimeters - declaration of contamination check prior to return (Rad 10).
Risk Assessment
Risk Assessment Form
Safety Policy
Model School Safety Policy
Supervision
Project Supervisory Requirement Form
Transport
Minibus Driver's Approval Form
Annual Radiation Inspection Checklist
Microsoft Word
PDF 
This form is the basis of the Safety Office's annual radiation inspection reports. Schools may wish to download the form to see the sort of issues that are checked and may wish to use the checklist themselves.
Annual Safety Report
Microsoft Excel
Microsoft Word
This form is to be submitted to the Safety Office on an annual basis by each school/department. Schools are requested to email their latest version of their Disaster Recovery Plan to the Safety Office (Paula Campbell) at the time of submitting their report. This will be forwarded to the University Incident Management Team.
Audit Checklists
These checklists could be used as a record by School Safety Officers or other members of staff to carry out routine inspection of workplaces. It is University Policy that an annual inspection must be carried out. There are examples of two checklists, one of a general nature and the other which is applicable to offices, computer rooms, lecture rooms and similar environments.
Certificate of decontamination for laboratory equipment used with hazardous substances
Microsoft Word
PDF
Display Screen Workstation Checklist
Microsoft Word
This checklist should be used for 'users' workstations to identify any problems with the equipment and/or set-up. It may be completed by a 'user' and then submitted to the local DSE assessor or School Safety Officer.
Display Screen Equipment 'users' eye test form
The University now provides free eye tests to DSE users using the Boots Corporate eye care system. The full procedure is given here. The triplicate form that needs to be taken to a Boots optician of your choice, must be obtained from your School/Departmental Safety Officer or DSE assessor. How the form should be completed is given here.
Entry by Contractors and Maintance Staff into Laboratories, Workshops and Other Hazardous Areas
Permit to Carry Out Maintenance work in a Hazardous Area.
Entry by Contractors and Maintenance Staff into Laboratories, Workshops and Other Hazardous Areas.
This procedure is intended to prevent exposure of maintenance operatives (contractors and maintenance staff) to hazardous processes and substances when entering laboratories, workshops and other hazardous areas.
The principles are:
- Entry of maintenance operatives into such areas is prohibited without the permission of a responsible person for the area. Signage with contact details to be displayed at the entrance to the room, suite, or building.
- The area shall be safe from process hazards for the maintenance work to proceed.
- Entry shall be subject to a permit confirming either that the area is clear of process hazards or specifying the precautions to be followed to ensure safety.
- Maintenance operatives from both the Estate Office and contractors are instructed in this procedure.
It is intended that the permit be completed as follows:
Planned maintenance - the entry form is emailed to the Helpdesk at the same time the works request is submitted. This will avoid a delay on the day.
Emergency work - a supply of the forms to be available in the area to be completed at the time.
Hot Work Permit
Microsoft Word
PDF
This form is to be used for controlling the risks assosciated with hot work such as Welding, Burning, Cutting, Grinding and working with Bitumen boilers etc.
When these activities are carried out in direct contact or in close proximity to flammable or combustible substances there is the risk of explosion, fire and the production of toxic substances, with the potential consequences of serious injury, ill-health and or damage to property and the environment. It is therefore necessary to have a control procedure to reduce the risks associated with Hot Work to an acceptable level.
The University Hot Work Procedure applies.
Laser User Registration Form
Microsoft Word
PDF
This is to be completed by new laser workers prior to starting laser-related work. Individuals should contact their school laser supervisor for further information on local procedures.
Laser Registration Form
Microsoft Word
PDF
This is to be completed following the purchase or acquisition of any new laser or indeed the change of use of an existing laser.
Personal Emergency Egress Plan (PEEP)
Microsoft Word
PDF
Project Supervisory Requirements Form
Microsoft Word
PDF
This form should be used as a record of the tasks that research students undertake where varying degrees of supervision is required depending on the experience and competence of the individual. The supporting University policy is Safe Supervision of Postgraduate & Undergraduate Students.
Registration form for individuals proposing to work with sources of radiation
Microsoft Word
This is to be completed by an individual who wishes to start working with radiation. This form must be completed and processed by the Safety Office prior to starting radiative work. Individuals should contact their Radiation Protection Supervisor for further information on procedures if further guidance is required.
Workers who will require access to Isostock (the system for recording acquisition, use and disposal of radiochemicals) are required to submit their Novell Username on the form. Registering on workers on Isostock is a two stage process.
- The first stage is to give access to Isostock and supply of a password to the worker's RPS. This is done by the Safety Office and can be processed immediately.
- The second stage involves enabling access to the server hosting Isostock. The username is forwarded to Information Services for this to be done. This might take a few days hence it is advised that an allowance be made for this when submitting registrations.
Radiation Protection Supervisor - Notification of Appointment
Microsoft Word
This form is to be completed by the Head of School and returned to the Safety Office to notify the appointment of a new Radiation Protection Supervisor. It is a legal requirement that Radiation Protection Supervisors are competent to perform their duties and consequently it is a University requirment that they attend a training course that has been approved by the Safety Office. RPS training is now provided through attendence at an external 2-day training course. This is mandatory for new appointments, which will not be accepted without this. Radioactive work cannot be undertaken in an area if a suitable RPS has not been appointed.
Radiation Protection Supervisors are expected to remain in post for a number of years and any transfer of duties must be planned to coincide with the availability of training. The prefered training provider runs several courses a year and it should be possible to enable the intended RPS to attend a course at relatively short notice - 2 to 3 months. The Safety Office will contribute towards the cost of the course but the School is responsible for travel and subsistance and any residual element of the cost of the course. The Safety Office contribution is subject to the outgoing RPS having been in post for a reasonable period. Frequent changes will not be funded.
Radiation Project Registration Form for working with Sources of Radiation
Microsoft Word
This is to be completed by the registered radiation worker (countersigned by the Radiation Protection Supervisor) and forwarded to the Safety Office for approval. Approval must be received by the Safety Office prior to commencing work.
Risk Assessment Form
Microsoft Word
This is the University's standard form for recording risk assessment of work activities. Guidance on how to carry out risk assessments is available.
Minibus Driver's Approval Form
Microsoft Word
This form should be completed for each minibus driver and kept within the School. Further explanation is given in Safety Office Circular "Minibus Safety P10/02A".
Manual Handling Risk Assessment Form
Microsoft Word
Further explanation is given in Safety Office Circular "Action on the Manual Handling Operations Regulations 1992 9/93B"
Radioactive Wast Transfer Note (Medical School)
Microsoft Word
This form is to be used to accompany solid and organic liquid radioactive waste when disposed of to the disposal contractor.
School Safety Policy Model
Microsoft Word
This form is to be used to create a personalised policy for your School/Department.
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