Preliminary Hazard Review Form

Principal Investigator directing or advising this work?*
First Last
Principal Investigator Phone number
Principal Investigator Email*
List the name(s) of other individuals who will be using this equipment or process:
First Name Last Name
Location where this will be conducted:
Department Building Office / Room number
Describe the work
Describe the work in some detail making clear what you plan to do, what equipment and materials (chemicals, etc.) are involved and what the objective(s) are:
Process parameters:
What is the normal operating pressure? What is the normal operating temperature?
Are any compressed gases employed*
- Yes
- No
List compressed gases and expected quantities
Hazardous Gases Quantity
Any hazardous liquid materials?*
- Yes
- No
List hazardous liquids and expected quantities
Hazardous Liquid Quantity
Any hazardous solid materials?*
- Yes
- No
List hazardous solids and expected quantities
Hazardous Solid Quantity
Have you added this process or equipment to your Safety Plan?
- Yes
- In process
- What is a safety plan?
- No
Who needs a Safety Plan? A safety plan is required for all areas that use hazardous materials, hazardous processes and storage of these items. Affected areas include, but are not limited to machine shops, Facilities Zone Shops, utility and facility chemical storage areas, agricultural locations (research farms, field labs, and extension locations) and laboratories (teaching and research). EHS SAFETY PLAN WEBSITE
Which of the following hazardous conditions may exist during operation?:*
- NONE
- Explosion
- Implosion (vacuum collapse)
- Contact with live electrical parts
- Working Alone or Outside Normal Working Hours
- Electrical Arc Flash (600 volts or higher)
- Thermal Burn (Hot or Cold materials)
- Chemical Exposure (Inhalation, Ingestion, Injection?)
- Exothermic Reaction
- Excessive Noise
- Allergic Reaction
- Radioactive Material Exposure
- Radio-Frequency Exposure
- Laser Use
- Intense Light
- Pinch point(s)
- Fall from height
- Struck by
- Caught in
- Sharps/Cuts
- Muscle strain
- Awkward postures
- Air contamination
- Water contamination
- Soil contamination
Does the process or equipment include any of the following features or equipment?*
- NONE
- Emergency Power Off Switch (EPO)
- Gas Monitoring
- Pressure Relief Device
- Emergency Gas Off Switch (EGO)
- Exhaust Flow Monitoring
- Heating Device
- Ventilated Enclosure
- Gas Cabinet
- Fume Hood

Preliminary Hazard Review Form

2620 Wolf Village Way
Raleigh, NC 27695

Phone: 919.515.7915

Fax: 919.515.6307

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First Name	Last Name

Hazardous Gases	Quantity

Hazardous Liquid	Quantity

Hazardous Solid	Quantity