cbme risk assessment audit declaration form

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  • 8/10/2019 CBME Risk Assessment Audit Declaration Form

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    CBME Risk Assessment Audit Declaration

    I, _________________, have read and understood the relevant sections of the HKUSTSafety and Environmental Protection manual. I am aware of my responsiilities withre!ard to the health and safety of myself and others and state that, to the est of my"nowled!e, the information provided in this wor" plan is complete and correct #

    I have attended and passed the following safety courses :

    1. Hazardous Waste Management (mandatory) M!"#

    $. !hemical %afety for &a'oratory sers (mandatory)M!"

    #. *ire %afety (mandatory)

    +. &aser %afetyM!"+

    ,. -iological %afetyM!"

    . /ressure %afetyM!",

    . 0thers :

    Are any of the following categories relevant to the proposed research?

    High voltage power supplies es 2o

    -iologically active materials es 2o

    3adioactive materials or ionising radiationsources

    es 2o

    2on4ionising radiation (56 microwaves6 lasers) es 2o

    Highly to7ic6 carcinogenic or mutagenic materials es 2o Highly flamma'le or e7plosive materials es 2o

    0peration under e7treme pressure ortemperature

    es 2o

    Status of Researcher

    ! " H8%9 CBME H8%9 2on H8%9 0thers

    #! " /h.;. M./hil. M.%c." */ 30/ %tudent Helper

    5isiting %cholar 3esearch 7change4= *aculty = 3esearch

    $nsurance Coverage

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    Assessment checked %y &echnical staff associated with A'' la%oratories in whichthe planned E()ER$ME*&A' work will %e undertaken!

    &a'oratory 3esponsi'le 9echnician (2ame) %ignature ;ate

    )lease list A'' la%oratories in which A*+ A*A'+&$CA' work will %e undertaken,Analytical 'a% -./01Spectroscopy and Surface Characteri2ation -./30

    Material )rocessing and Characterisation -.40

    &a'oratory 3esponsi'le9echnician 2ame

    >?uipment 9raining 3e?uired@2

    9raining !ompleted@2

    5 *ote,

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    I have had my worA plan checAed 'y the relevant technical staff associated will allla'oratories in which the planned worA will 'e undertaAen and also 'y my *aculty researchsupervisor. I have considered their suggestions and feed'acA and have modified the worAplan accordingly.

    Researcher

    2ame %ignature ;ate

    Assessment checked %y research supervisor-s0

    2ame %ignature ;ate

    2ame %ignature ;ate

    Authori2ed %y CBME Departmental Safety 6fficer -DS60

    2ame /rofessor Bohn -arford %ignature ;ate

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