Forms

Building Captain/Floor Manager Application Form

Fill out this form if you are interested in becoming a Building Captain or Floor Manager to help increase building safety and safety awareness.

The title link is to the online form. If you want to download a paper copy click here.

Dorm Safety Fire Extinguisher Checklist

RAs and CAs use this checklist to record your weekly fire extinguisher inspections. Turn them in to your Residential Life Coordinator at the end of the month.

Hazard Registration Form

This form should be filled out for all laboratories and shops on campus. It is designed to identify hazards that can be found in a lab/shop.

Reminders will be sent out annually to review the information and update it as necessary.

Hazard Door Sign

Use this PDF to fill out the hazard door sign. This is the door sign from the Annual Laboratory Hazard Registration Form above.

Biohazard Work In Progress Door Sign

Post this sign outside the lab whenever work is being done with potentially biohazardous materials.

EWU Biosafety Manual

Please click this link to access the current EWU Biosafety Manual.

Regulated Chemical Use Form

Everyone working with chemicals should submit this form annually to EH&S.  This will ensure that anyone who needs respiratory protection for their chemical work is identified.

The title links to the web based form. If you would like to download a paper copy, click here.

Analytical X-ray Monthly Survey Record

Use this PDF form to record monthly surveys of analytical x-ray equipment on campus.

Analytical X-ray Daily Use Log

Use this PDF form to record use of analytical x-ray equipment on campus.

Hazard Registration Form

This form should be filled out for all laboratories and shops on campus. It is designed to identify hazards that can be found in a lab/shop.

Reminders will be sent out annually to review the information and update it as necessary.

Ladder Inspection Form

Use this ladder inspection form to ensure the ladder being used is in good condition before each use.

Confined Space Entry Permit

This form must be filled out before any entry into a Permit-Required Confined Spaces. This form is to be filled out by the Entry Supervisor and must be filed at Rozell upon completion of the confined space work.

Hot Work Permit

This form must be completed before any hot work takes place in a confined space. This form is to be completed along with the Confined Space Entry Permit above. It is to be filled out by the Entry Supervisor and filed with the Confined Space Entry Permit.

Abandoned Lock/Tag Removal Form

This form must be filled out anytime a supervisor or Lockout Coordinator removes a lock or tag that was left behind. Must be signed by the employee who left the lock/tag and submitted to the Facilities Operation Manager.

Equipment Inventory Form

Use this to record all equipment and systems that require lockout/tagout procedures.

Group Lockout/Tagout Procedure Worksheet

Fill out and use this worksheet for all group lockout/tagout procedures.

Individual Lockout/Tagout Procedure Worksheet

Fill out and use this worksheet for any individual lockout/tagout procedure that involves more than one energy source or energy isolation point.

Lockout/Tagout Equipment Specific Procedure

Every item on the Equipment Inventory Form requires a procedure. All procedures must be reviewed annually for compliance.

Tagout-Only Justification Form

Submit this form to the Facilities Operation Manager to get approval for Tagout-Only procedures.

Aerial Lift forms

Aerial Lift Pre-Inspection Form

Use this form to document the safety inspection of an aerial lift before you operate it. This form should be kept in Rozell with the lift clipboard when the lift is returned.

Lift Operators Personal Equipment Use Log

Use this form to log the amount of time you spend using powered lifts. A copy should be submitted to EH&S every three years during your lift training.

Fall Protection Forms

Anchorage Inspection Form

This form must be completed by employees prior to using an anchorage connector, every day the anchorage connector is used. It must also be filled out by the installer when a new anchorage connector is put in.

Fall Protection Work Plan

A Fall Protection Work Plan must be in place for any work with a fall hazard above 10 feet. The plan must be completed prior to the start of work and must be readily available at the work site for inspection.

Harness Inspection Form

This form must be filled out by the employee prior to donning a harness to document that they have fully inspected the harness for defects. If the harness will be used multiple times in one day, fill out the inspection form once at the start of the day.

Horizontal Lifeline Inspection Form

This form must be filled out by the installer of the horizontal lifeline after installation and by employees prior to each day's use of the horizontal lifeline.

Lanyard Inspection Form

This form must be filled out by the employee prior to using a lanyard to document that they have fully inspected the lanyard for defects. If the lanyard will be used multiple times in one day, fill out the inspection form once at the start of the day.

Self-Retracting Lifeline Inspection Form

This form must be filled out by the employee prior to using a Self-Retracting Lifeline (SRL) to document that they have fully inspected the SRL for defects. If the SRL will be used multiple times in one day, fill out the inspection form once at the start of the day.

Vertical Lifeline Inspection Form

This form must be filled out by the installer of the vertical lifeline after installation and by employees prior to each day's use of the vertical lifeline.

Part-Time, Temporary and Student Health & Safety Orientation Form

Supervisors must fill out this form for each part-time, temporary and student employee. This records that the employees have received appropriate health and safety training before they begin work.

Information for Persons Voluntarily Using Respirators

Fill out this page if you are voluntarily using a respirator at Eastern. It is used to ensure you understand what voluntary use of a respirator is and the benefits and hazards associated with this decision. Keep a copy for your records and send a copy to EH&S.

Initial Medical Questionnaire for Employees with Animal Contact

Employees should use this form to enroll in the Animal Exposure Occupational Medicine Program. Please follow all the instructions found on page one.

Download this form and open it from the saved location if you get a warning about needing to update your PDF viewer.

Initial Medical Questionnaire for Students with Animal Contact

Students should use this form to enroll in the Animal Exposure Occupational Medicine Program. Please follow all the instructions found on page one.

Download this form and open it from the saved location if you get a warning about needing to update your PDF viewer.

Follow-Up Medical Questionnaire for Employees with Animal Contact

Employees, use this form to update your medical information in the Animal Exposure Occupational Medicine Program. This form should be used if there are changes to your health or allergy status after you have completed the Initial Medical Questionnaire above.

Please follow all the instructions found on page one.

Download this form and open it from the saved location if you get a warning about needing to update your PDF viewer.

Follow-Up Medical Questionnaire for Students with Animal Contact

Students, use this form to update your medical information in the Animal Exposure Occupational Medicine Program. This form should be used if there are changes to your health or allergy status after you have completed the Initial Medical Questionnaire above.

Please follow all the instructions found on page one.

Download this form and open it from the saved location if you get a warning about needing to update your PDF viewer.

Hepatitis B Declination Form

Use this form if you have occupational exposure to bloodborne pathogens and you DO NOT want to receive the Hepatitis B vaccination. This form must be filled out and sent to EH&S.

Filling out this form does not prevent you from requesting the vaccination at a later date.

Informed Refusal for Medical Evaluation

Use this form if you are injured at work and you choose not to go immediately to a medical professional for evaluation. This form should be sent to EH&S when you submit an incident report.

This form does not prevent you from seeking medical attention at a later time for this injury.

Information for Persons Voluntarily Using Respirators

Fill out this page if you are voluntarily using a respirator at Eastern. It is used to ensure you understand what voluntary use of a respirator is and the benefits and hazards associated with this decision. Keep a copy for your records and send a copy to EH&S.