Safety Checklist for Unpaid Individuals with Potential Exposure to Workplace Hazards Volunteer Educational Experience Applicant name: _____________________________________________________Date of Birth:____________________ Host Name: ________________________________________________________________Host Phone:______________ Host Department/Division:____________________________________________________________________________ Who will train and supervise the individual?______________________________________________________________ Instructions: As the Host, you are accepting the responsibility for ensuring the safety of the individual named above while working under your supervision. Please discuss each item below with the individual and have him/her sign where indicated along with your initial certifying you have provided the information indicated. Exclusions: 
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Minors under the age of 15, and not part of a structured educational sponsored program are not permitted. No one under the age of 15 may be compensated for their work. No one under the age of 16 may be exposed to any infectious materials including human blood and body fluids regardless of the use of personal protective equipment. No one under the age of 18 may be exposed to radioactive materials. Action Item Yes No 1.
Will the student work in a laboratory? (If yes, contact the Office of Research Safety, Laboratory Safety Training must be completed). 2.
Will the student work in a non‐laboratory area with the potential for exposure to hazardous chemicals? (If yes, contact the Office of Research Safety, General Chemical Safety Training must be completed. 3.
Will the student work with or in an area with radioactive materials, equipment producing ionizing radiation, or lasers? (If yes, contact the Office of Research Safety, Radiation Safety Training must be 4.
Will the student work with laboratory animals? (If yes, Animal Care Training must be completed. Contact ACC Office at: OOACC@uchc.edu to arrange this). 5.
Will the student be exposed to human blood or infectious materials? (Minimum age 16 years old.) (If yes, contact the Office of Research Safety, Bloodborne Pathogen Training must be completed). 6.
Will the student require personal protective equipment? (If yes, then the student’s supervisor must provide it, train the student in its proper use, and inform the student about the tasks requiring such use). 7.
Students are prohibited from: 
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8.
Applicant Host Initials Initials Indicating Completion
Wearing a respirator or exposure to an environment requiring a respirator. Work near/with unprotected high voltage equipment. Work with machines/equipment posing a physical hazard.
Discuss safety procedures regarding: a. Use of autoclaves N/A b. Disposal of hazardous wastes, except as directed by P.I. N/A c. Work with hazardous chemicals except for those used in the quantities and manner approved by the P.I. N/A d. Activities or work with unfixed human materials and other potentially infectious materials that could result in potential exposure (splash, contaminated sharps, etc.) irrespective of any personal protective equipment use N/A e. Use of lasers or systems containing lasers N/A f. Work with radioactive materials and/or radiation producing equipment (i.e., x‐ray) N/A g. Other Departmental restrictions N/A 10. Brief student/volunteer on emergency evacuation procedures, the location of the laboratory assembly point, dialing of x7777 for emergency assistance and location of fire pull stations. 11. Brief student/volunteer that in case of a spill that they are: to leave the immediate area, not clean it, and promptly seek assistance from the Host or Research Safety at x2723. 12. Provide at no cost to the student/volunteer appropriate personal protective equipment. The participant should not be doing tasks with potential for a liquid splash of hazardous materials or airborne objects. 13. Discuss protective gloves and what gloves to use and provide these at no cost. 14. Emphasize that no food or drink is allowed in laboratory areas where chemicals, radioactive materials and human materials/infectious agents are used. 15. Outline their authorized activities and work, the potential risks and the procedures and equipment that must be followed to minimize those risks. Specific items covered may be listed below. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 17. Outline the UConn Health mandates for prompt reporting of any injury or exposure that may affect health. The student/minor must report this BOTH to the Host and by phone to Human Resources at x8367 or Volunteer Services at x2381 if the minor is a volunteer. Student/Volunteer requiring medical evaluation or emergency treatment should visit the Emergency Department. 9.
Discuss location and use of emergency eyewash and location of emergency shower (without shower activation). Stress that in case of contact with a hazardous material immediately flush that body area with copious amounts of water. 16. Designate yourself (and a staff member if possible) as responsible for supervising the minor and answering questions. NOTE: Minors cannot work unattended in the laboratory. Keep copy of form in student file, return original form to the Office of Research Safety – MC3930 8/13/01 (safetymin.doc) Rev. 6/06, 6/07, 4/08, 4/09, 5/10, 5/11, 5/12, 5/13, 5/14