MONASH UNIVERSITY SCHOOL OF CHEMISTRY
DECLARATION FORM V7.4 (JUNE 2010)
This form has been prepared in order for the School to exercise a reasonable level of control of its operations including a duty of care to all and to ensure ALL personal
exercise a reasonable duty of care to themselves, others and the School. It highlights the requirements prior to commencement of work AND those on completion of stay no
matter how short that stay may be. Supervisors should note that they have the greatest general responsibility; this should be demonstrated. If these requirements are not met,
they may be charged for all costs such as waste disposal, cleaning etc. including time.
You have a right to access personal information that Monash University holds about you, subject to any exceptions in relevant legislation. If you wish to seek access to your
personal information or enquire about the handling of your personal information, please contact the University Privacy Officer on 9905 6011.
SECTION 1: STARTING UP
Details 15-16 must be completed before issued with keys and allocated a room.
1. Family Name .........................................................................................................................................................................
2. Given Names (Including middle initial) ...........................................................................................................................
3. Title (Prof. Dr. Mr. Mrs. Ms. Miss) ...................................................................................................................................
4. Address (Private) ..................................................................................................................... Post Code ........................
5. Home Phone No. .................................................................................................................................................................
6. Supervisor ..............................................................................................................................................................................
7. Category (Visitor; Contractor; Academic Staff; General Staff; Grant Appointed Staff; Visiting Scholar; PhD;
MSc; MscPrelim; Honours; Vacation; Casual; Undergraduate) Please Circle One
8. Commencement Date ..........................................................................................................................................................
9. Termination Date .................................................................................................................................................................
10. Cost Centre ........................................................................... Fund ................................................................................
I currently have a Scholarship
Yes
No
Type of Scholarship ..............................................................................................................................................................
Please go to (Bld 19/127) Anna Severin, to register on the School’s Post Graduate, PhD and Masters database.
Please go to (Bld 19/125) Monika Walker, to register on the School’s Honours and Masters Pre-Lim database.
11. Keys Required (Please get the key number from the barrel/lock on Door e.g. SC12)
1. Office Key No. .....................................
2. Lab Key No. ..........................................
Extra Keys Required
3. Key No. ..................................................
4. Key No. ..................................................
5. Key No. ..................................................
Room No. ........................ Bld. ..................... Deposit $ ......................
Room No. ........................ Bld. ..................... Deposit $ ......................
Room No. ........................ Bld. ..................... Deposit $ ......................
Room No. ........................ Bld. ..................... Deposit $ ......................
Room No. ........................ Bld. ..................... Deposit $ ......................
12. Phone Number/s Allocated (to room/lab) .................................... / .......................................... /
I ........................................................................................................................ (Full Name; Printed) declare that I
will adbide by the following requirements during my stay at the School of Chemistry.
...............................................................................................................
Signature
...............................................................................
Date
...............................................................................................................
Supervisor’s Signature
..............................................................................
Date
Computer Accounts will be created by IT and a username will be issued to you by reception.
Please contact IT on 51777 for your password.
13. ID Number .................................................................................. 14. Issue No. On ID Card ..................................
Office Only/Username ............................................
Acad
Gen Res Hons MSc PhD
CGC
WSC
15. I was issued with a Safety Induction Kit by the Safety Officer or Deputy and accepted my Duty of Care
(This includes receiving and giving advice as required under Monash OHSE policy)
16. A fully completed Risk Assessment form has been completed and approved by the Safety Officer before I
commence my initial project. I agree that subsequent Risk Assessment forms will be completed for each new
project or significant changes in my initial project prior to conducting practical work in any laboratory.
Checked (Safety Officer) ..................................................................................... Date ..................................................
*Craig Forsyth (Bld 23S/G51A) and Boujemaa Moubaraki (Bld 23S/165) will be available twice a week
on MONDAY and THURSDAY mornings (10-12:30pm) to sign the necessary forms and undertake the
appropriate awareness training.
* Please note that NO keys will be issued until the Risk Assessment has been completed and signed.
SECTION 2: REQUIREMENTS ON COMPLETION
17. I, ................................................................................................................. ID No. ...........................................................,
declare that I left my work area/s (Room/s ............................................. in a clean and tidy state including
providing my supervisor with all relevant documentation. Disposing of all unwanted chemicals etc. Returning
all borrowed equipment etc. Removed all unwanted email etc.
If you are a first aider please advise the First Aid Coordinator (M. Kennedy 54574) of your departure.
18. I have paid all outstanding accounts to the School and returned all my keys. I have my key deposit of $ .........
returned to myself, upon showing my receipt given and the time paid.
* Please note that marks and key deposits will be withheld until satisfactory completion of item 17
above *
...............................................................................................................
.......................................................................
Signature
Date
...............................................................................................................
Supervisor’s Signature
Date Issued
After Hours/Security
Keys & Deposit
Photocopier + Phone List
Scimitar – Chemistry Store
.......................................................................
Date
Date Returned/Deleted