Forms & Checklists
Overview
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.
Note: The following components must be fulfilled in order to be respirator qualified.
- Training – Compliance Brief: Filtering Facepiece Respirators and Masks – 16 min. (Online @ CSU Learn)
- N95 Respirator Request Form (Online) – Attach a copy of the N95 online training “Certificate of Completion” when submitting the N95 Respirator Request form
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
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)
Lockout/Tagout
- LOTO Audit Form (LOTO App. B)
Respirators
- Respirator Cleaning Log (Resp. Prot. App. A)
- Respirator Fit Test Log (Resp. Prot. App. B)
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
Risk Management Forms
- 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
- CSULA Site Visit Checklist
- Individual General Release
- Class General Release
- Class General Release for Athletics
- Photo Release
- Photo Release (Spanish)
