Revised: 10/1/14
Biology, Chemistry, Physics
123 Science Wing Jarvis Hall
University of Wisconsin-Stout
Menomonie, WI 54751- 0790
715/232-2626
715/232-4056 – Fax
STUDENT CARD ACCESS USE AGREEMENT
Having card access to any space within Jarvis Hall Science Wing is a privilege. By signing this form you agree to:
 Access only the rooms/building indicated below
 Access these spaces only if there is reason to and only during the times and dates indicated below
 Never let another person use your card to access the facility
 Never allow an unknown or unauthorized person enter the space with you
 Obtain proper lab training before working within any of the facility’s labs
Safety of students, faculty, staff and the public is closely linked to security measures. Disciplinary actions, including
potential termination of employment, will be taken if misuse of card access privileges is evident.
Student Name (printed): ___________________________________ Student ID: ________________________
Student Email: ___________________________________________
Name of Supervisor (printed): _______________________________
Reason access is needed: ___________________________________
TO BE FILLED OUT BY SUPERVISOR:
Reason access is needed: ___________________________________
In order for students to be granted lab access, D2L Laboratory Safety Training Modules 1-9 and Quizzes 1-3 are required before access can
be granted. The completion of this form will prompt Laboratory Safety Training enrollment and once the 3 quizzes have been completed
with 100% accuracy, the student will be granted card access. Documentation of lab specific/SOP training is your responsibility.
Please indicate any additional training you want for your student:
BSL-2 Access Training
Chemical Storage
Corrosives
Fire Hazards
PHS
(Required for JHSW 247, 249, 257 & 267)
PPE
Toxins
Ventilation (Hood Use)
No Additional Training
* A refresher training session must be completed yearly after initial training session.
ACCESS GROUP FULL TITLE
EXP. DATE
ACCESS TIMES
(5/31,8/31, or
12/31)
(7A-10P or 24/7*)
ACCESS DAYS
*24/7 access should only be granted to faculty/staff. If a student requires 24/7 access, please include a written justification for department chair and building supervisor approval.
_______________________
___________
_____________________________
____________
Signature of Student
Date
Signature of Supervisor
Date
Please deliver completed form to Rebecca Hoeft’s mailbox in JHSW 331A, for processing.
TO BE FILLED OUT AFTER FORM IS SUBMITTED TO REBECCA HOEFT AND AFTER LABORATORY SAFETY TRAINING IS COMPLETED:
____________________________________
Training Completion Approval (Rebecca Hoeft, CHO)
____________
Date