OCCUPATIONAL SAFETY AND HEALTH DECLARATION FORM Full Name: (Please use block letters) Department & Faculty: NRIC / Passport No.: Nationality: Student / Staff Matric No.: (If applicable) Supervisor’s Name: Position (Tick where applicable) ( ) Staff (Academic / P&P) ( ) Visiting Professor ( ) Post-Doc. ( ) Student (Postgraduate) ( ) Student (Undergraduate) ( ) Staff (Lab & Support Staff ) ( ) Senior Research Fellow ( ) Research Fellow ( ) Research Assistant ( ) Others: (specify) Declaration I, the above named, declare that I have read, understood the safety handbook and will therefore be able to ensure that my work is carried out in a safe manner in a safety conscious environment in compliance with all regulations as laid down by the faculty and university. In the event of any accident which is due to my negligence and/or non-compliance to safety regulations and procedures, I will indemnify the University on all liabilities. Signed: ………………………………………… Date: …………………. Witnessed By:…………………………………. Date: …………………. (Academic Supervisor, signed & stamped) IMPORTANT NOTICE: All lab users MUST complete and sign this form before they are allowed to work in the laboratories / workshops. All students MUST complete 2 copies during registration / enrolment and return the forms to the Dean’s Office for retention in the student’s personal file and with the HoD Office / Departmental Safety & Health Committee. Failure to do so will render the registration / enrolment incomplete and will be barred from working in the laboratories / workshops.
PROJECT INFORMATION Project Title: (Please use block letters) Mobile Phone: List of chemicals: 1. 2. 3. 4. 5. 6 7. 8. 9. Name of waste: Name of Equipment: 1. 2. 3. 4. 5. Laboratory Name: Witnessed By:…………………………………. (Supervisor Laboratory / Biochemistry Program Coordinator ,signed & stamped) Date: ……………………. IMPORTANT NOTICE: All lab users MUST submit a copy of the MATRIC CARD together with this form Please clean up the work area after finish the experiment Please use the equipment following the manual instruction