Date:
PDF ___
Thesis Student ___
Volunteer ___
Other ______________________
Supervisor(s):
Project Name:
Project Description (brief):
Ethical Reviews
Animal Subjects?
If yes, Ryerson Animal Control Committee (ACC) approval is required.
Human Subjects?
If yes, Ryerson Ethics Board (REB) approval is required.
YES / NO
YES / NO
Potential Hazards
Biological Agents
Chemical Agents
Compressed Gases
Lasers (> Class 3a)
Machinery
Shop Equipment
Press, Drills, Saws, etc.
Machinery with exposed moving parts.
Radiation (Ionizing)
Isotopes
X-ray
Temperature Extreme High or Low
Voltage (High)
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
If you answered YES to any potential hazards, you will need to take additional training courses (Biosafety, Laser Safety,
Radiation Safety, X-Ray Safety, etc.), and/or review standard operating procedure (SOP) with your supervisor.
Other Potential Hazards (list):
Describe/list standard operating procedures and personal protective equipment, applicable to project.
Examples:
1. High Temperature Tube Furnace - Furnace SOP/instructions available
Insulating gloves to be worn when adding/extracting samples. Tube not to be over-pressurized.
2. Class 4 Laser Laser operation SOP available
Eye protection and skin protection to be worn at all times. Beam stops to be used. Ventilation required during cutting.
Working Off-Campus
Location(s):
Purpose:
Briefly list any safety training/requirements for non-Ryerson institutions:
(Note, some training requirements may be redundant but are required for purposes of liability.)
I hereby acknowledge my role and responsibilities as defined under Ryerson Universitys Environmental Health and Safety
Management System (www.ryerson.ca/ehss), and I agree to adhere to the responsibilities outlined for all employees,
including but not limited to, participation in requisite training, adherence to safe work practices, and reporting of
accidents, serious incidents, and potentially hazardous conditions to my supervisor.
Student/Researcher Signature:
Date:
Supervisor Signature:
Date:
Retain a copy for your records and submit a copy to Department Safety Officer.
For additional information, see http://www.physics.ryerson.ca/safety