RSC Approval Application Form for Lasers

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Office use only.
Date Received:
RSC identifier number:
\
Research Ethics & Compliance Support
RSC Approval Application Form
Is this project a:  a) NEW Project OR
 b) Project renewal
Please advise previous RSC identifier(s) if answer b) above…………………………
& EXPLAIN the relationship between the applications in section 2.
1. Project supervisor
Name:
Position (school/organisation):
Relevant radiation training and experience: (training type, location & year trained)
Phone:
Email:
Postal address:
2. Project details
Title:
Briefly describe the project including the aims, experimental approach and description of
laser use:
Please advise any UNSW Ethics
approval number(s) relevant to this
project
Proposed duration of project (from -
1
to):
3. Laser equipment details
Class
Type (eg
YAG)
Power (W)
Wavelength(nm)
NOHD
Laser Hazard Evaluation Check List
Laboratory location:
Entrance to Laser Laboratory
Appropriate warning signs
Entryway controls (one of the following):
· non-defeatable (interlocked doors)
· defeatable (interlocked doors)
· procedural: PPE available upon entry
· door/curtain at entry way;
· visible/audible signal (eg., lighted sign)
SWP available/current
· naming LSO for laboratory
· listing authorised operators
· limited access by spectators
· copy of Laser Safety Policy
Designated area for protective eyewear
· appropriate eye protection clearly identified
when multiple wavelengths in use
Skin protection where appropriate (ie. UV lasers)
Windows/doorways covered/restricted
Panic button / E-stop available
Laser controlled area within a laboratory
Laser hazard area clearly identified
Laser beam path enclosed to prevent accidental reflections of beam into adjacent work-spaces
Laser and optical components
Laser warning signs & labels
Protective housing
Protective housing interlocks
Key control
Beam stop/attenuator
Reflective materials out of paths way
Laser secured to table or base
Optical components secured to table or base
Beam above / below eye level (sitting & standing)
Non-Beam Hazards
Electric shock/high voltage exposed
Fire potential
Vapour/particle generation
Hazards or toxic chemicals
2
Tick
Suitable earthing of metal laser table
4. Project personnel:
Name
Role in team (staff/ research
assistant/ PhD student)
Training (local induction, laser
safety at ADFA, etc.)
5. Attachments:
The following documents MUST BE attached or its SafeSys Item Number given
Documents
State SafeSys Item Number or “Attached”
Risk Management Form
Safe Work Procedure
Copy of all users licence
6. Declarations:
This application will not be presented to the RSC without all of the signatures
Note1*: if there is more than one Project Supervisor, each must sign
Note2*: where more than one facility will be used (work and/or storage), please provide signatures for
each facility
Note3*: where a research group is carrying out work at another groups facility, the Heads of both
groups must sign
Note1* Project Supervisor (named in Section 1)
Print Name:
Signature:
Date:
Note2* Laboratory/Facility Manager/Laser Safety Officer
Print Name(s):
Email:
Signature(s):
Date:
3
Note3*Head of School or Research Organisation (for affiliated Organisations)
Print Name and Position:
Email:
Signature:
Date:
Please submit electronic word version of the completed form, pdf scan of signature page and all attachments via
email to the RSC Support Officer: [email protected]
4
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