Fillable This form is intended as an addendum to (UCLA Health)

Fill Online, Printable, Fillable, Blank This form is intended as an addendum to (UCLA Health) Form

Use Fill to complete blank online UCLA HEALTH pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

This form is intended as an addendum to (UCLA Health)

On average this form takes 6 minutes to complete

The This form is intended as an addendum to (UCLA Health) form is 1 page long and contains:

  • 2 signatures
  • 16 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your UCLA Health forms online.

BROWSE UCLA HEALTH FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Revised 1/23/2020 Page 1 of 2
HEALTH SCIENCES VOLUNTEER OFFICE
VOLUNTEER REQUEST: HIGH-RISK LAB ACTIVITIES
This form is intended as an addendum to the VOLUNTEER/UCLA SRP STUDENT SCOPE OF DUTIES form in which the
requested laboratory activities fall under UCLA Policy 906: Undergraduate Researcher Laboratory Safety.
Only current UCLA Students may perform activities within this addendum. Volunteers and/or UCLA SRP Students may
NEVER be “working alone” in a lab and all activities must be under the “supervision” of a “supervisor” (may not be
another undergraduate researcher). Some activities will require “direct supervision” (see definitions in page 2).
Please indicate which lab activities the Applicant, who must also be a current UCLA Student, will be performing
(additional safety training required):
Working with any materials or equipment that may require additional training or direct supervision as determined
by the “Principal Investigator” (PI)/Supervisor. (Please indicate the materials or equipment below.)
Conducting any procedure involving hydrogen peroxide or organic peroxides (must have a detailed protocol).
Conducting a scale-up chemical procedure that is more than four times a prior experiment or uses more than 100
grams of substrate.
Handling of BSL2 materials, including primary human cells/tissues/blood but excluding established human cell lines.
Working with reactions under pressure, using glass or metal reactors, or which may become pressurized.
Working with open beam class IIIB or class IV lasers. (See Policy 906: Attachment B, item 9 for definitions and examples.)
Working with ultrafast lasers. (See Policy 906: Attachment B, item 9 for definitions and examples.)
Working in a BSL2+ facility.
Working in shops (e.g. machine or wood).
Working with radioactive compounds.
Working with pyrophoric reagents.
Performing any hot work (e.g. welding) which requires a permit.
Performing operations which use an open flame.
Performing radiosynthesis.
Performing flow cytometry.
Please explain how you, the PI/Supervisor, will ensure risk is mitigated for the Applicant to perform such activities:
The applicant will conduct laboratory procedures independently as set by the PI/Supervisor in which proficiency
will be demonstrated under direct supervision. (Please describe the laboratory procedures in detail below.)
By signing below, the following parties agree that they understand the following:
The Inviting Supervisor attests that the provided information on this form is true and correct and that ANY changes
or updates will be reported to and approved by the UCLA Health Sciences Volunteer Office.
The Applicant attests that they understand this form serves as an addition to their Scope of Duties Form and that
they are NOT permitted to perform any duties NOT listed or approved within their Scope of Duties Form.
_
Inviting Supervisor’s Name Inviting Supervisor’s Signature Date
_
UCLA Student’s (Applicant) Name UCLA Student’s (Applicant) Signature Date
UID: Expected Graduation Date (MM/YY):
click to sign
signature
click to edit
click to sign
signature
click to edit
Revised 1/23/2020 Page 2 of 2
Policy 906: Undergraduate Researcher Laboratory Safety
Definitions:
Direct Supervision is when the individual is being directly watched during experimentation by the Principal
Investigator, Supervisor, the assigned mentor, or another fully trained lab member who is at least a graduate
student, postdoctoral scholar, or staff member.
Principal Investigator is a faculty or staff member who is responsible for the research laboratory. A full
administrative definition of a UCLA Principal Investigator can be found at UCLA Policy 900: Principal
Investigator Eligibility.
Supervision is when the individual is not working alone due to the presence within the room or adjacent room
within hearing range of the Principal Investigator, Supervisor, the assigned mentor, or another fully trained lab
member who is at least a graduate student, postdoctoral scholar, or staff member.
Supervisor is an experienced researcher who provides guidance and training to the Undergraduate
Researcher. The Supervisor can be the Principal Investigator, the assigned mentor, or another fully trained lab
member who is at least a graduate student, postdoctoral scholar, or staff member. The Supervisor may not be
another Undergraduate Researcher.
Working Alone is when an individual is working unaccompanied, such that assistance is not readily available
should an injury, illness, or emergency arise. Alone is interpreted as being out of direct visual contact or
hearing range with another lab worker for more than a few minutes. It can occur during normal working hours
as well as during evening, night or weekend hours and even in the same general area as others.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

This form is intended as an addendum to (UCLA Health)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document