Supervisor's Department Annual Safety Training Request Form

For UMaine Supervisors / Employees that are responsible for conducting the required Department Annual Safety Training to their employees.

We can help develop a tailor made lesson plan / outline that you may use to conduct your work area Department Annual Safety Training to your employees. Fill out the appropriate boxes and click the submit button at the bottom of the form. When we receive your request, we will contact you to either arrange a site visit with you in your workplace or communicate by some other method.

If you are not a UMaine employee, please do not complete this request - your form will not be processed.

Last Name:
First Name:
Phone Number:

E-mail: (where the confirmation will be sent)

To give us a better idea of the type hazards that your employees experience and help identify training requirements - in the section below, please click all boxes that apply. We understand that the list is not all inclusive, and you may be performing tasks that are not identified. You may state any additional items in the last section.

Do you have employees who: (click all that apply)

operate a computer terminal for more than four (4) consecutive hours on a daily basis?

remain behind and assist persons in orderly evacuation of buildings in an emergency?

are required to use a fire extinguisher?
frequently are required to lift, carry, handle heavy or bulky materials and/or objects?
are exposed to slip/trip/fall hazards such as slippery floors, poor housekeeping, uneven walking surfaces, loading docks, etc?
are exposed to elevated surfaces and fall hazards?

use ladders?

work on scaffolds?

use vehicle mounted elevating work surfaces (telescoping and/or articulating)?

operate a forklift, walker-stacker, or other industrial truck (other than those registered with the Department of Motor Vehicles)?

use hand tools - including knives, box cutters, etc.
use power tools?

perform servicing or maintenance on machines or equipment?

work in an area where machines and equipment may be serviced?
work with or around electricity?
use welding / soldering equipment?

enter (or standby for the entry of another worker) into a confined space?

work in an area where confined spaces are located?

work in or around trenches/excavations?

use farming/agricultural machines or equipment?

apply or work in an area that uses pesticides (i.e. farms, greenhouses, nurseries, or forests)?

work in remote areas (for example, conducting fieldwork) where there is an absence of medical care (clinic, hospital, etc.) in near proximity ?

conduct watercraft operations or academic/scientific research on a vessel?

conduct any type of tree work (trimming trees) or logging operation?

wear Personal Protective Equipment (PPE)?

are exposed to excessive noise?

use lasers?

handle or use radiation?
are exposed to extreme heat / extreme cold?
may be exposed (clean up, handle, perform first aid, etc.) blood or other bodily fluids?
are exposed to respiratory/inhalation hazards such as chemicals, nuisance dusts, asbestos, silica, etc?
are exposed to hazardous chemicals (accidental or possible)?

use hazardous chemicals in a laboratory?

are required to clean up chemical spills?

work with or around hazardous waste (such as Universal Waste Lamps or a Satellite Accumulation Area (SAA)?
transport, receive, or package hazardous waste?

Please add any additional tasks/hazards that your employees may experience that is not listed above:

Provide any questions or comments that you may have.

We will e-mail you soon after we receive and process this form. If you have not received a confirmation e-mail (or a phone call) within 5 working days, please contact us at 581-4055.

Thank you for using our on-line Department Annual Safety Training Request Form. We look forward to working with you.

Click  , or to clear this form click  and your request will not be sent.