Application for Working In
Laboratory/Workshop After Hours
On completion, please return this document to the Department/School Office.
1.0
Information
Name of Applicant:

Staff

Honours Student

Post Graduate Student
Building Name and Number:
ID Card Number:
Contact mobile number:
Commencement Date: ____________________________
Period of Work
Completion Date:
____________________________
From: ________________________
Duration of Work
To:
________________________


Limited
Overstay
Categories of Work



Low Risk Tasks
Moderate Risk Tasks
High Risk Tasks
Risk Assessment Undertaken
(for Moderate-High Risks Tasks)

YES
After Hours


Weekday
Weekday


Weekend/Public Holiday
Weekend/Public Holiday
Brief description of tasks, equipment used
including reason for use of the laboratory after
hours.
Issue date: July 2013
Review date: July 2014

NO
Page 1 of 2
2.0

1
Declaration by Applicant
I confirm that I have my supervisor’s permission to work these hours and have undertaken a risk
assessment for the tasks.
Name of Applicant
Signature
2
Approval by supervisor
Name
Signature
3
Approval by Head of Department
Name
Signature
4
Departmental Safety Officer
Name
Signature
3.0
Details of Student(s) Accompanying (if any)
Name of Student
ID number
1
2
3
4
5
Issue date: July 2013
Review date: July 2014
Page 2 of 2