Forms & Checklists

~~Forms and Checklists

The forms and checklists have been assembled from many different parts of the EH&S Program. Where forms come from procedures, the procedure title and appendix are given. The Procedures are found in the RM/EHS Procedures Manual. Most Emergency Preparedness checklists and forms are found in Emergency Preparedness. However, some can be found in the list below.
Procedure Appendices
Confined Space
Supervisor Safety Checklist (Confined Space App. B)
Confined Space Entry Permit (Confined Space App. C)
Non‐Permit Entry Certification (Confined Space App. D)
Electrical Safety
High Voltage Switching Procedures & Receipt (Elect. App. A)
Energized Electrical Work Permit (Elect. App. C)
Safety Meeting Documentation Checklist (Elect. App. D)
Emergencies Action Plan
Emergency Checklist Form (AP 408 App. 8.3)
Evacuation Drill Evaluation Form (AP 408 App. 8.4)
Ergonomic Program
Ergonomic/Worksite Evaluation Request (AP 425 App. 8.1)

Ergonomic Evaluation Request For Temporary Telework.pdf
Fire Protection
Portable Fire Extinguisher Check Sheet (Fire Protect. App. A)
Injury / Illness
Hazard Incident Report Form (IIPP App. 8.2)
Supervisor Report of Occupational Injury or Illness (IIPP App. 8.3)
Employee Report of Occupational Injury or Illness (IIPP App. 8.4)
Ladder Safety
Annual Ladder Inspection Form (Ladder Safety App. 9.1)
Portable Scaffolds
Tele-Tower Scaffold Checklist (Portable Scaffold  App 8.1)
Perry Scaffold Checklist (Portable Scaffold  App 8.2)
LOTO Audit Form (LOTO App. B)
Respirator Cleaning Log (Resp. Prot. App. A)
Respirator Fit Test Log (Resp. Prot. App. B)
Voluntary Respirator Use Acknowledgement (Resp. Prot. App. D)
Welding, Cutting, Hot Work
Hot Work Permit (Weld./Cut./Hot Work App. 8.1)


Supervisors Checklists
Supervisor’s New Employee Safety Checklist
Supervisor’s Safety Orientation Checklist General
Supervisors Heat Stress/Heat Illness Checklist
Supervisor’s Safety Orientation Checklist for Laboratories
Building Administrators Emergency Checklist
Vehicle/Cart Unsafe Practice Report
Instructors/Students Checklists and Forms
Click here for Faculty Checklists for Student Health & Safety

Risk Management Forms
Request for Travel Form
Request for Travel Supplemental Information Form
Emergency Information Guidelines Form
State Vehicle Driver Program Enrollment Form
Authorization to Use Privately Owned Vehicles on State Business- Form STD 261
Vehicle Accident Report Form for State Drivers
Travel Expense Claim Form
CUSLA Site Visit Checklist
Individual General Release
Class General Release
Class General Release for Athletics
Photo Release
Photo Release (Spanish)