Fillable FILLABLE Laser Inventory Form

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FILLABLE Laser Inventory Form

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U.S.A. forms for Tennessee Technological University

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Environmental Health and Safety
Laser Safety Program
Laser Inventory Form
All lasers or laser devices (Class 3b or 4) brought to Tennessee Tech University must be inventoried.
B
ldg:
Room#:
Responsible Person (P.I.):
Email:
Dept:
Class:
Manufacturer:
Model #:
Serial #:
Medium:
Type (CW/pulsed):
Max. Power Output:
Wavelength (
λ
):
Intended Use (medical, research, other):
L
ist all laser users: Comments:
Please complete the following survey:
Bas
ic Laser Safety Training completed by all users YES NO
A
ppropriate PPE for all users YES NO
L
aser Warning Door sign YES NO
S
OP posted YES NO
If any laser is returned to the manufacturer, discarded, or sent to other departments or institutions you must notify
the Environmental Health and Safety at 372-3227 or sdifurio@tntech.edu
N
ame: Date:
S
ignature:
Please send the completed form to Sarah DiFurio, sdifruio@tntech.edu, or Box 5041
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FILLABLE Laser Inventory Form

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Completed 17 March 2020

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