RMEHS Forms and Checklists

• Supervisor Safety Checklist (Confined Space App. B)
• Confined Space Entry Permit (Confined Space App. C)
• Non‐Permit Entry Certification (Confined Space App. D)

• High Voltage Switching Procedures & Receipt (Elect. App. A)
• Energized Electrical Work Permit (Elect. App. C)
• Safety Meeting Documentation Checklist (Elect. App. D)

• Emergency Checklist Form (AP 408 App. 8.3)
• Evacuation Drill Evaluation Form (AP 408 App. 8.4)

• Ergonomic/Worksite Evaluation Request
• Ergonomic Evaluation Request For Temporary Telework

• Portable Fire Extinguisher Check Sheet (Fire Protect. App. A)

• Employee Report of Occupational Injury or Illness (IIPP App. 8.4)
• Hazard Incident Report Form (IIPP App. 8.2)
• Report a Safety Concern
• Supervisor Report of Occupational Injury or Illness (IIPP App. 8.3)

• Annual Ladder Inspection Form (Ladder Safety App. 9.1)

• 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)

Note: The following components must be fulfilled in order to be respirator qualified.

1. Training – Compliance Brief: Filtering Facepiece Respirators and Masks – 16 min. (Online @ CSU Learn)
2. N95 Respirator Request Form (Online) – Attach a copy of the N95 online training “Certificate of Completion” when submitting the N95 Respirator Request form.

• Hot Work Permit (Weld./Cut./Hot Work App. 8.1)