Form for Doorway Safety Information

Please submit form after completion: or

Room Information

Department: Brockhouse Institute for Materials Research Date : May 1, 2006
Building: Room: (e.g. 248, B149; 245C (lettered rooms), 248(A,B,C,D) (single sheet for multiple lettered rooms)
You can use a forward slash separator (i.e. /). Avoid: \:,.
Primary Use:

Personel Information

Email address of person responsible for maintaining form:

Please note that you are not required to publicize your home phone number and by default it is not displayed unless you mark it as public.
The number in either case is kept on file for the use of security. Cellphone numbers provided are always private.

Supervisory:

Name

Building/Room

Phone Extension

Home Phone Number

Cellphone


Make Public?


Make Public?


Make Public?


Make Public?

Technical Staff:

Name

Building/Room

Phone Extension

Home Phone Number

Cellphone


Make Public?


Make Public?


Make Public?

Other Users:

Name

Building/Room

Phone Extension

Home Phone Number

Cellphone


Make Public?


Make Public?


Make Public?


Make Public?


Make Public?

Safety Information

Hazards:

Select known hazards in room:

List Other Hazards in room:

Select all that apply by clicking with mouse.
(In Windows, hold Ctl key down for multiple selections,
Use the equivalent key in other OS's)

Separate items with comas.

Safety Precautions:

Select precautions to be taken in room:

List Additional Safety Precautions:

Select all that apply by clicking with mouse.
(In Windows, hold Ctl key down for multiple selections,
Use the equivalent key in other OS's)

Separate items with comas.

Safety Equipment:

Select safety equipment available in room

List Additional Safety Equipment:

Select all that apply by clicking with mouse.
(In Windows, hold Ctl key down for multiple selections,
Use the equivalent key in other OS's)

Separate items with comas.

Finally, you need to submit it: or