UC SAN DIEGO: ENVIRONMENT, HEALTH AND SAFETY Proposed Project Checklist for Minors Performing Research in Laboratories This section to be completed by the PI & Supervisor prior to beginning work Provide details of the research project and types of experiments to be performed: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Project Start Date: _________________________________ Project End Date: __________________________ Will the minor be exposed to and/or work with any of the following hazardous materials? Note: Minors cannot work in spaces where Controlled Substances are present. Chemical Hazards Biohazardous Materials Radioactive Materials/Lasers List the following that the minor will be using: - Chemical Hazards: _______________________________________________________________________ - Biohazardous Materials: ___________________________________________________________________ - Radioactive Materials/Lasers: _______________________________________________________________ Is this a classroom or educational outreach program? No Yes List program name: ______________________________________________________ Signatures: PI/Supervisor verify that the above information is accurate PI: ______________________________________ Supervisor: ______________________________________ This section to be completed by the minor prior to beginning work Minor’s name: ____________________________________ Email: _________________________________ Date of Birth: ______________ Prior research laboratory experience: ________________________________ Signatures: Minor and parent/guardian have reviewed the above information Minor: ___________________________________ Parent/Guardian: _________________________________ Send completed form, along with WAIVER OF LIABLITY and RULES FOR MINORS, to: [email protected]or Minors in Lab, MC 0090 For more information, look at http://blink.ucsd.edu/go/minorsinlabs, email, or call 858-534-8035 . Principal Investigator (PI): ___________________________ Supervisor: _______________________________ PI email: __________________________ MC: __________ Supervisor email: __________________________ PI phone: ________________________________________ Supervisor phone: __________________________ EH&S Review: CSO: ____________________________________ RSO: __________________________________ BSO: ____________________________________ LSO: __________________________________ RSM: ____________________________________ Add’l Restrictions Apply: CSO BSO RSO LSO 08/08/2014
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UC SAN DIEGO: ENVIRONMENT, HEALTH AND SAFETY
Proposed Project Checklist for Minors Performing Research in Laboratories
This section to be completed by the PI & Supervisor prior to beginning work
Provide details of the research project and types of experiments to be performed:
Project Start Date: _________________________________ Project End Date: __________________________
Will the minor be exposed to and/or work with any of the following hazardous materials? Note: Minors cannot work in spaces where Controlled Substances are present.
Chemical Hazards Biohazardous Materials Radioactive Materials/Lasers
List the following that the minor will be using:
- Chemical Hazards: _______________________________________________________________________
Is this a classroom or educational outreach program?
No Yes List program name: ______________________________________________________
Signatures: PI/Supervisor verify that the above information is accurate PI: ______________________________________ Supervisor: ______________________________________
This section to be completed by the minor prior to beginning work
Date of Birth: ______________ Prior research laboratory experience: ________________________________
Signatures: Minor and parent/guardian have reviewed the above information Minor: ___________________________________ Parent/Guardian: _________________________________
Send completed form, along with WAIVER OF LIABLITY and RULES FOR MINORS, to:
[email protected] or Minors in Lab, MC 0090 For more information, look at http://blink.ucsd.edu/go/minorsinlabs, email, or call 858-534-8035
.
Principal Investigator (PI): ___________________________ Supervisor: _______________________________
PI email: __________________________ MC: __________ Supervisor email: __________________________
PI phone: ________________________________________ Supervisor phone: __________________________
1. Never participate on a scheduled assignment alone in any laboratory environment without direct, immediate adult supervision from the PI and/or supervisor.
2. Complete and follow safety training specific to the hazards in the laboratory.
3. Always wear closed-toe shoes and long pants while in any laboratory to reduce the
amount of exposed skin.
4. Always wear the personal protective equipment (PPE) as directed and dispose of it appropriately. This PPE includes goggles, gloves, coats/gowns, and other face/body protection as dictated by the hazard being worked with or around. Always remove PPE when leaving the work area.
5. Always follow the instructions of the PI and/or supervisor.
6. Always report any accident (regardless of severity) immediately to the PI and/or
supervisor.
7. Always keep your hands away from your face and wash them well with soap and water prior to leaving any laboratory area and after removing gloves.
8. Never eat, drink, chew gum, apply lip balm, or touch contact lenses while in any
laboratory environment.
9. Always tie back long hair to minimize hazard risk in the lab.
10. Always ask questions if you don’t understand the safety requirements or hazards involved.
11. Review the Proposed Project Checklist. ___________________________________ ___________________________________ Signature of Minor Signature of Parent/Legal Guardian ___________________________________ ___________________________________ Printed Name of Minor Printed Name of Parent/Legal Guardian ________________________ ________________________ Date Date
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in
hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do herebyrelease, waive, discharge, and covenant not to sue The Regents of the University of California, itsofficers, employees, and agents from liability from any and all claims including the negligence ofThe Regents of the University of California, its officers, employees and agents, resulting inpersonal injury, accidents or illnesses (including death), and property loss arising from, but not limitedto, participation in The Activity.
________________________________________ ________________________________Signature of Parent/Guardian of Minor Date Signature of Participant Date
Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot beeliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity toanother, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) majorinjuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3)catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these andother risks that are inherent in The Activity. I hereby assert that my participation is voluntary andthat I knowingly assume all such risks.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents ofthe University of California HARMLESS from any and all claims, actions, suits, procedures, costs,expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement inThe Activity and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption ofrisks agreement is intended to be as broad and inclusive as is permitted by the law of the State ofCalifornia and that if any portion thereof is held invalid, it is agreed that the balance shall,notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, andindemnity agreement, fully understand its terms, and understand that I am giving up substantialrights, including my right to sue. I acknowledge that I am signing the agreement freely andvoluntarily, and intend by my signature to be a complete and unconditional release of all liabilityto the greatest extent allowed by law.
_______________________________________ ____________________________________Signature of Parent/Guardian of Minor Date Signature of Participant Date
