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Forms

 

This page contains the links to a variety of Environmental Health and Safety, as well as Risk Management forms. A brief explanation explaining when the form is needed appears to the right of each link.

 

Environmental Health

Indoor Air Quality Reporting

Use this form to report issues related to the indoor environment in this building.  Air quality issues may include concerns with temperature, humidity, ventilation, odors, or air pollutants that may be causing health or discomfort symptoms. 

 

 

Facilities Management

Hot Works Permit - (Updated 04 2012)

Required in advance of any work requiring heat or open flame to complete within a facility owned, leased or managed by University of Houston–Downtown (UHD). Includes welding, torch cutting, grinding, brazing, flame soldering, thawing pipes with torches, and other work where there is potential for fire. If you are requesting this permit, you should be either working from a work order, university purchase order, departmental order or a signed contract.

 

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Laboratory Safety

Guide to the Globally Harmonized System of Classification and Labeling of Chemicals (GHS)

The laboratory PI is responsible for the instruction of all laboratory personnel in the safe use of chemicals. Information regarding the classification and safe use of chemicals can be found at this web site.

(From the U. S. Department of Labor)

Project Hazard Assessment Form

Special precautions are needed when handling select carcinogens, reproductive toxins, and substances that have a high degree of acute toxicity. The PI must ensure precautions are taken in order to minimize the risk of exposure to these substances.

This form must be filled out and approved before any project with hazardous materials may be considered.

Memorandum of Understanding and Agreement Registration of Biohazardous Materials and Recombinant DNA

All experiments involving recombinant DNA, biological toxins, and other biohazards must be approved by the UH-System Biological Safety Committee. Approval can be obtained by filling out this form.

UHD will have a standing membership on the UH-System Biological Safety Committee until such time as there is a need to establish an independent Biological Safety Committee at UHD. In summary, faculty working with biological hazards must complete both and MUA (and get it approved by UH) and a PHA which must be approved by all levels at UHD.

Student Permission to Work Independently After Hours Form

This form should be filled out by research students or students in some high-impact courses requesting permission to work independently after hours (between 7PM and 7AM).

This form must be turned in to the Chief Safety Officer (NS Chair) in the NS Office at least 10 days before work is performed. Laboratory activities which could place the student in a potentially hazardous situation will be denied. Experiments that can be easily performed during normal working hours will likely also be denied. In denied cases, the CSO and the PI should work together until the project is modified or until the project can be completed during normal business hours.

Student Visitor Accident Report Form Any student or visitor accidents or injuries that could result in a potential claim against UHD

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Food Safety

Food Services Application

[Note: List being developed on when this application is/is not required.]
Open Flames Permit for Special Events -(Updated 03/01/2012) If candles or an open flame (for example, a sterno) will be used at a special event. Permit must be posted at the location of the event during the entire time of the event. Cooking areas and all adjacent areas must be inspected for sparks/fire at least 30 minutes after the event is over.

 

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Emergency Evacuation Assistance Request Forms

Emergency Evacuation Assistance Form - Employee If an employee has a temporary or permanent disability that impairs his or her mobility, or if assistance is needed to evacuate the building during an emergency
Emergency Evacuation Assistance Form - Student If a student has a temporary or permanent disability that impairs his or her mobility, or if assistance is needed to evacuate the building during an emergency

 

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Risk Management Reports/Claim Forms

The following reports are to be turned in to UHD Risk Management (One Main Building room 621 S 713-222-5340) for forwarding to UH Risk Management within 24 hours of the incident.

(Click Here for Additional Information)

 

Student, Visitor or Contractor Accident Report Form

Any student, visitor or contractor accidents or injuries that could result in a potential claim against UHD

Automobile Accident Procedure Reporting Form

09/01/13 to 09/01/14 Accident

Any vehicle accident involving a UHD vehicle (whether the vehicle was damaged or not) or a student/visitor/vendor vehicle possibly damaged by UHD property/personnel
Property Loss Claim Report Any property loss that occurs as a result of occurrences such as fire, theft, or natural disaster

Blanket Insurance Accident/Sickness Claim

03/01/13 to 03/01/14 Accident

Student injured or sickened as a result of participating in the programs covered by “Blanket Insurance

 

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Employee Accident, Injury or Near Miss

(Click Here for Additional Information)

When you become aware of any potential hazard, near miss or spill,

report it to the EHS Office immediately

(713-221-8404 or One Main Building room 621 S)

Report of Safety / Health Hazard and Near Miss

 

Workers' Compensation Policy - (02.A.25)

Medical care and treatment, and compensation for work related injury or illness

Supervisor Report of Accident

If employee seeks medical care

(Must be completed and forwarded to Benefits Coordinator within 24 hours)

Witness Statement

If other individuals witness the incident/accident or other individuals have information regarding the incident/accident.

(Must be completed and forwarded to Benefits Coordinator within 24 hours)

Employee's Report of Injury (SORM-29)

For occupational injury, illness or exposure

(Must be completed and forwarded to Benefits Coordinator within 24 hours)

Authorization for Release of Information Form (SORM 16)

If employee seeks medical care

(Must be completed, signed by employee and forwarded to Benefits Coordinator within 24 hours of the medical care)

Employee's Election Regarding Use of Sick and Annual Leave

Injured employee must choose whether or not they will utilize accrued sick leave and any annual leave before receiving workers' compensation income benefits.

(Must be completed and signed, employee and forwarded to Benefits Coordinator within 24 hours of the first full day of lost time.)

 

Reference SORM80 for additional Information.

 

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Ergonomics

(Click Here for Additional Information)

 

Office Ergonomic Checklist Self assessment checklist that covers your office chair, keyboard, mouse, work surface, monitor, workstation accessories and work habits
Building A Better WorkStation Video presentation on workstation adjustments that improve ergonomics.
Optimal Personal Comfort Guidelines to ensure good posture and obtain optimal personal comfort in your workspace
Selecting and Ergonomic Office Chair Features to check for when you are selecting a desk chair

 

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Page maintained by cookm@uhd.edu

Last updated or reviewed on 1/31/14

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