P
PA
AU
U LL S
SC
CH
HE
ER
RR
RE
ER
R II N
NS
ST
T II T
TU
UT
T –– S
SA
AF
FE
ET
TY
Y S
SH
HE
EE
ET
T
Ring  SR SINQ SLS other
D
Deeccllaarraattiioonn LLiisstt ooff H
Haazzaarrddoouuss S
Saam
mppllee//TTaarrggeett M
Maatteerriiaall aanndd E
Exxppeerriim
meennttaall E
Eqquuiippm
meenntt
((oonnee ffoorrm
f
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e
a
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i
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m
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i
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)
m for each item/experiment)
Title of Experiment:
Experiment Number (if known)
Instrument / Beamline
Date of Experiment (if known)
SAMPLE
TARGET
Toxic
name of substance
chemical formula
form of material
amount of material
size of material
container/sealing:
transport:
by user [ ]
removed:
by user [ ]
/
to
from
powder [ ]
liquid [ ]
solid [ ]
shipped separately [ ]
stored at PSI [ ]
no [ ] / yes [ ] , specify:
ingestion [ ]
inhalation [ ]
other
[ ] , specify:
other [ ]
already at PSI [ ]
disposed off by PSI [ ]
skin contact[ ]
eye contact [ ]
contact person: P. Hasler
Already radioactive:
Activation expected:
Bio. Hazard
no [ ] yes [ ]
no [ ] yes [ ]
activity:
activity:
Bq isotopes:
Bq isotopes:
IAEA supervision [ ]
IAEA supervision [ ]
contact person: A. Fuchs
no [ ] / yes [ ] , specify:
contact person: K. Ballmer
Reactive:
no [ ] / yes [ ] , specify:
inflammable: [ ]
explosive: [ ]
in contact with:
air [ ]
water [ ]
Equipment during transport/experiment/storage:
magnetic field
Tesla
pressure
kbar, m^3
heating
K, Watt
cryogenics
K, coolant
thin window
X-ray
kV
laser
, W
high voltage
kV
other:
Other Safety Aspects:
corrosive: [ ]
heat [ ]
other:
contact person: P. Hasler
contact person
C. Wernli
S. Bondt
P. Hasler
Ch. Geiselhart
L. Simons
A. Fuchs
T. Lippert
W. Fleischmann
Y. Loertscher
transp.
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
exp.
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
storage
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
no [ ] / uncertain [ ] / yes [ ], specify
contact person: Y. Loertscher
I confirm that the information above is correct as well as to respect all safety regulations valid for PSI.
Date:
E-Mail:
Signature:
Please return this form (include attachments if necessary) not later than 3 weeks prior to the experiment to:
W. Bertl (Ring: High Energy), E. Morenzoni (SR), J. Schefer (SINQ), M. Wang (SLS)
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Document1
P
PA
AU
U LL S
SC
CH
HE
ER
RR
RE
ER
R II N
NS
ST
T II T
TU
UT
T
D
Deeccllaarraattiioonn LLiisstt ooff H
Haazzaarrddoouuss S
Saam
mppllee//TTaarrggeett M
Maatteerriiaallss
aanndd
E
x
p
e
r
i
m
e
n
t
a
l
E
q
u
i
p
m
Experimental Equipmeenntt IInnffoorrm
maattiioonn S
Shheeeett
Telephone/Telefax:
+41 (56) 310 xxxx
E-Mail:
firstname.name@psi.ch
Post Office:
5232 Villigen PSI, Switzerland
Telephone Switch Board:
+41 (56) 310 2111
Questions? Safety Contact Persons:
Toxicants, Reactivity
Radioactivity
X-Ray
Thin Windows
Biological Hazard
High Voltage
Magnetic Fields
Laser
Cryogenics
Fire Safety
Cranes, Elevators,
Hoisting Devices
Pressurized Systems
Transport dangerous
goods
General
Return Form to:
Ring-Experiments
(High Energy
Experiments)
SR-Experiments
SINQ-Experiments
SLS-Experiments
other
Name
Building
Phone
FAX
Hasler, Peter
Fuchs, Albert
Fuchs, Albert
Simons, Leopold
Kurt Ballmer
Fleischmann, Wilhelm
Wernli, Christian
Lippert, Thomas
Geiselhart, Christian
Bächli, Alois
OFLB/005
WBGA/C36A
WBGA/C36A
WMHA/B24
OFLC/102
OKWA/998
OFLD/006
OFLB/U110
WKSA/101
OFLC/U105/
2842
4487
4487
3501
4165
2366
2357
4076
4531
2037
Reinhard, David
Bondt, Silvio
Zimmermann, Ulrich
OKWA/999
OKWA/999
OFLC/U107
5448
2952
4262
2384
2309
Loertscher, Yves (safety of.) OFLC/U104
2350
2309
Bertl, Wilhelm
OFLC/007
3651
5230
Morenzoni, Elvezio
Schefer, Jurg
Wang, Meitian
Loertscher, Yves (safety of.)
WLGA/017
WHGA/244
WSLA/215
OFLC/U104
3670
4347
4175
2350
3294
3294
5292
2309
2309
2309
3717
4417
2309
2688
4586
5166
PSI-Phone-Directory:
http://cgi.web.psi.ch/pb/
Forms for Download:
http://services.web.psi.ch/safety/dokumente/safety_sheet/safetysheet.html
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