Revised Aug-20
College of Natural Sciences and Mathematics California State University, Long Beach
OFFICE USE ONLY
Pass Tests: □ Yes □ No Form Entered: Key Personnel Notified:
Safety Program Form
Directions: Please answer the questions below. Email the form with the trainee section completed to your supervisor.
Your supervisor will fill in their portion of the form and email the fully completed form to CNSM-Safety@csulb.edu.
Please use Adobe Acrobat or Reader to fill out this form.
Trainee Section
Last Name: First Name: Dept:
Your Supervisor(s): Campus ID#:
What is your job? (select one):
○ Staff
○ Grad Student
○ SA/Work Study○ Faculty
○ TA ○ GA
○ Undergrad Student
○ Post-doc/Research Assoc.
○ Formal Volunteer
○ Guest
Parti
cipation Agreement: I have undergone CNSM General Safety Training. I understand my rights and obligations as an
employee, student, volunteer, and/or supervisor under the provisions of the Cal/OSHA "Right-to-Know" hazard
communication regulations. I agree to work at all times in complete accordance with all CNSM Safety policies and
procedures, the CNSM Chemical Hygiene Plan, the campus Injury and Illness Prevention Program (IIPP) and to protect
the health and safety of myself and those around me. I will not knowingly undertake a potentially hazardous task for
which I have not been adequately trained. I am aware of the environmental, health and safety resources provided by the
University, College and the Department, and will use them as necessary.
I understand and agree to the Participation Agreement (please type your initials): Date:
Supervisor Section
This section must only be filled out by the above-named individual’s supervisor.
Work by the trainee identified above will require involvement with the following (check ALL that apply):
X-Ray Generating Machines
Human Blood, OPIM or Biohazardous Agents (BSL-2)
Lasers (open beam Class 3B or Class 4)
Cryogenic Materials (liquid nitrogen, dry ice, liquid helium)
Peroxide Forming Compounds (ether, THF, etc.)
Laboratory Instruction (computer labs excluded)
Particularly Hazardous Substances (PHSs)
The above-named individual is authorized for after-hours facility use (see the CNSM Lab Security Regulations):
○ Yes ○ No
Supervisor Agreement: I certify that the above-named individual has or will receive additional safety training related to
specific hazards associated with research projects under my direction. Examples include, but are not limited to,
hazardous chemical SOPs, Cal OSHA carcinogens, lab-specific procedures and equipment. Project work cannot be
performed unless required training is provided and documented.
I understand and agree to the Supervisor Agreement (please type your initials): Date:
Note: CSULB uses the Risk & Safety Solutions (RSS) software system to provide hazard assessment information to CNSM employees, volunteers, and
students working in laboratory or research work environments. If you are a supervisor, you may be required to complete a risk assessment in RSS
and build a group for those under your supervision. If you are joining an established group, you will be asked to review and acknowledge an
assessment for each group in which you become involved. For more information, contact your supervisor, or the Science Safety Office at
562.985.5623 or
CNSM-Safety@csulb.edu
