Colorado School of Mines - Office of Graduate Studies
Regulated Materials Checkout
Required of Master's Thesis and Doctoral Degrees
Does not apply to: Those students who are enrolled in Economics, Math, Computer Science, or the Liberal Arts and
International Studies MIPER programs.
Student Name:
CWID:
Degree Level:
Select Degree Level
Major:
Select Degree Title
Department:
Select Department
EMAIL:
Date:
Regulated Materials Checkout: Certain materials used or produced during graduate research are regulated by state and federal
law. The abandonment of such materials on School property is prohibited. Faculty advisors shall actively monitor the acquisition,
storage and disposal of such materials by graduate students and shall act to prevent the accumulation of abandoned material in
facilities under their jurisdiction.
I (the student named above) certify that the following which were in my possession have been returned to the EHS
Department or placed in the care of the responsible faculty member.
Indicate action by placing the following next to each item – “ C ” to indicate action completed or “ N/A ” to indicate not
applicable
Unused chemical reagents and/or industrial chemicals
select
action
Compressed gases
select
action
Radioactive material and/or pathogenic organisms
select
action
Environmental, chemical mineral or metal samples (properly labeled to indicate content/identity)
select
action
Syringes, blades, broken glass and similar laboratory “sharps”
select
action
Waste which contains any of the aforementioned materials and empty reagent containers originated by me
has been turned in to the EHS Dept. for disposal
select
action
Describe any exceptions:
Student Signature:
By signing below, advisors confirm regulated materials have been properly accounted for and have fulfilled their
responsibility to maintain a safe work environment.
Printed Name
Advisor:
Co-advisor:
Department Head or Program Manager:
GS Regulated Materials Checkout - Revised 8/24/2015
Signature
Date