Forms and Checklists

Aerial Lift / Scissor Lift Field Training Form

Bloodborne Pathogen Exposure Control Assessment

This form is used to tailor your department's Bloodborne Pathogens Exposure Control Plan.

Bump Check Log

Use this form to "bump check" (field test) the MSA Orion Multigas Confined Space Meter.

Chemical Pickup Form (.doc)

Chemical Pickup Form (.pdf)

Chemical Reuse Form

For chemicals or products which are suitable for redistribution to other departments.

Competent Person Certification Record

Computer Workstation Checklist

This checklist is used by the employee after they have completed the required annual training. It may also be used to conduct an evaluation of your own workstation.

Confined Space Emergency/Rescue Services Notification

Use this to ensure that rescue services are available to UMaine employees working in permit-required confined spaces.

Confined Space Entry Permit

Confined Space Evaluation Form

Continuity of Operations Plan (COOP) - Sample (also see Continuity of Operations Plan FAQ)

Department Annual Safety Training Checklist

The area supervisor or their designee must conduct the required training on the following items listed on this checklist on an annual basis. This checklist may also be used by the supervisor as documentation of training.

Emergency Action Plan Survey

This form will assist you in developing your Emergency Action Plan.

Emergency Call Card Form & Instructions

Two cards. One card is filled out and returned to SEM with your inventory, and one is posted on the door of your chemical use, or storage area.

HAZCOM Self-Audit Checklist

Hot Work Permit

A Hot Work Permit must be completed prior to welding, cutting, or brazing operations that occur outside of a designated welding area as described in the UMaine Welding, Cutting and Brazing Policy. Hot Work Permits are also required when welding, cutting, or brazing operations are conducted on used pipes, drums, tanks, barrels, or other containers.

Incident Report Form (for reporting property damage or injuries to visitors, students, or general public) - do not use this form for employee injuries.

N/A

Ladder Inspection Checklist (for portable step ladders)

Medical Testing - Pre-Employment Health and Safety Checklist This checklist is intended to determine and document what medical testing is required for an employee (classified by job title) during a post-offer, pre-employment physical. Click here for directions to help you fill out the form.

Oil Spill/Leak Report Form

Personal Protective Equipment Assessment/Certification

Respirator Medical Evaluation Questionnaire (Cutler Health)

Respiratory Protection Voluntary Use Form

Satellite Accumulation Area Inspection Log

Tier I - Investigation Report Form

The purpose of this form is to provide a more detailed description of the incident. A thorough understanding of the task being performed; and identification of contributing conditions will help us to take appropriate corrective actions, thereby reducing risks.

Training Record for Specialized Safety Training

Training Roster