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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