Safety and Environmental Management
Forms and Checklists
|Name | Description||Revision|
|Aerial Lift / Scissor Lift Self-Audit Checklist||4/7/2009|
This form is used to tailor your department's Bloodborne Pathogens Exposure Control Plan.
|Bloodborne Pathogen Hepatitis B Vaccination Declination Form||8/30/2009|
|Bloodborne Pathogen Sharps Injury Log||8/30/2009|
Use this form to "bump check" (field test) the MSA Orion Multigas Confined Space Meter.
|Chemical Hygiene Plan Certification and Annual Review||12/10/2010|
|Chemical Hygiene Plan - Lab Safety Training checklist||N/A|
|Chemical Spills (See Minor Chemical Spill Record)|
Chemical Pickup Form (.doc)
Chemical Pickup Form (.pdf)
For chemicals or products which are suitable for redistribution to other departments.
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.
Use this to ensure that rescue services are available to UMaine employees working in permit-required confined spaces.
|Confined Space Self-Audit Checklist||4/13/2009|
|Cranes and Hoists Daily Inspection||1/7/2005|
|Cranes and Hoists Monthly Inspection||1/7/2005|
|Cranes, Hoists, and Slings Self-Audit Checklist||4/7/2009|
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.
|Energized Electrical Work Permit||1/31/2007|
This form will assist you in developing your Emergency Action Plan.
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.
|Event Manager Security/Safety Planning Form||11/30/2012|
|Fall Arrest Harness Training Form||5/10/2006|
|General Area Safety Checklist||03/08/2013|
|Hazardous Waste Determination Request Form||4/18/2008|
|HAZCOM Training Checklist||3/5/2009|
|HAZCOM Training - Supervisor's Lesson Plan||3/14/2007|
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 Facility Emergency Coordinators||09/28/12|
Incident Report Form (for reporting property damage or injuries to visitors, students, or general public) - do not use this form for employee injuries.
|Injury/Illness Report Form (for reporting all work related employee injuries/illnesses - whether they result in medical attention or not)||N/A|
|Lab Safety Checklist||03/11/2013|
|Lab Cleanout Checklist||2/12/2008|
Ladder Inspection Checklist (for portable step ladders)
|Lockout / Tagout Self Audit Form||10/01/2012|
|Machine Shop Safety Checklist||3/7/2005|
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.
|Medical Testing - Supplemental Health and Safety Checklist This checklist is intended to determine and document what medical testing is required for an employee (classified by job title) as the result of a change in the employees duties.||12/1/2008|
|Minor Chemical Spill Record||1/9/2009|
|Pesticide Workers' Checklist||9/28/2010|
|Pesticide Workers' Training Checklist||7/28/2008|
|Powered Industrial Truck Operator Evaluation||4/27/2005|
|Powered Industrial Truck Operator Training Certification||11/20/2003|
|Powered Industrial Truck Pre-use Checklist||4/20/2005|
|Powered Industrial Truck Self-Audit Checklist||03/27/2013|
|Pre-Startup Checklist for New Installations or Alterations||9/5/2008|
|Radiation: Authorized Isotope User Application||12/31/2009|
|Radiation: Ionizing Radiation Producing Equipment Registration||12/31/2009|
|Radiation: Isotope Receipt Form||12/31/2009|
|Radiation: Personal Dosimeter Application||11/01/2010|
|Radiation: Radioisotope Receipt Utilization and Disposal Record||06/03/2013|
|Radiation: Request for Radioactive Waste Pick-up||12/31/2009|
|Radiation: Sealed Source Registration||12/31/2009|
|Radiation: Survey Meter Registration||12/30/2010|
|Radiation: Wipe Testing Procedure||07/31/2009|
|Respiratory Protection Voluntary Use Form (for H1N1 Virus)||5/1/2009|
|Satellite Accumulation Area Self-Audit Checklist||4/6/2007|
|Theatre Production Management of Change Approval Sheet||4/7/2009|
|Theatre Production Process Design Review Sheet||4/7/2009|
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.
|Toxic Substances Control Act (TSCA) Research Exempt Substance Notification||4/1/2009|
|Training Requirements Checklist||4/1/2007|
|Trenching and Excavation Inspection Log||8/1/2008|
|Trenching and Excavation Notification Form||7/5/2012|
|Trenching and Excavation Safety Checklist||8/1/2008|
|Universal Waste Inspection Checklist||4/6/2007|
|Universal Waste Storage Area Inspection Log||3/2/2004|
|Universal Waste Storage Area Inspection Log (Remote SQG Sites)||1/17/2011|
University of Maine, Orono, Maine 04469
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