Preliminary Hazard Review Form Your proposed work, process or project is required to have an EHS Hazard Review due to the potential safety and health risks it may present. This form is the first necessary step in performing an EHS Hazard Review for your equipment or process. Please complete this form and submit at your earliest convenience. Contact the Equipment Safety Engineer at 919-513-1422 for guidance on completion or any other EHS matter. Principal Investigator directing or advising this work?* First Last Principal Investigator Phone numberPrincipal Investigator Email* List the name(s) of other individuals who will be using this equipment or process:First NameLast Name Location where this will be conducted: Department Building Office / Room number Describe the workDescribe 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*YesNoList compressed gases and expected quantitiesHazardous GasesQuantity Any hazardous liquid materials?*YesNoList hazardous liquids and expected quantitiesHazardous LiquidQuantity Any hazardous solid materials?*YesNoList hazardous solids and expected quantitiesHazardous SolidQuantity Have you added this process or equipment to your Safety Plan?*YesIn processWhat is a Safety Plan?NoWho 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 WEBSITEWhich 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 PhoneThis field is for validation purposes and should be left unchanged.