Laser Hazard Evaluation Form - Safety at NMSU

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Environmental Health & Safety
New Mexico State University
MSC 3578, Box 30001
Las Cruces, NM 88003-8001
LASER HAZARD EVALUATION FORM
Laser Owner (PI) Name:
Department:
LSO: David Schoep (EH&S)
Laser Operator(s):
Laser Location (Building / Room):
Manufacturer:
Email: [email protected]
Serial Number:
☐2
☐3a
☐3b
Laser Type (eg. Nd:YAG):
Continuous Wave Laser:
Pulsed Laser?
Email:
Telephone: (575) 646-1023
Telephone:
Date of Manufacture:
Model Number:
Laser Class: ☐1
Telephone:
☐Yes
☐4
NMSU Property Number:
Wavelength(s) (nm):
☐Yes
☐No
Beam Diameter at Aperture (cm):
☐No
Average Power (W) [Continuous only]:
Pulse Rate (Hz):
Pulse Duration (ns):
Pulse Energy (J):
Beam Divergence: full angle (mrad):
Additional Process & System Description (use additional pages as needed)
Commercial Laser:
Key Switch: (or computer code):
Beam Attenuator:
Equipment Manual On Hand:
Protective Housing Label:
Manufacturer’s Label:
Options or Modifications:
Wavelength(s):
Ocular MPE:
Minimum OD (intrabeam):
Intrabeam NOHD:
Lens or Laser NOHD (m)
Fiber Optic NOHD (m) (if applicable)
Protective Housing Interlocks Functional:
Emission Indicator:
Remote Interlock Indicator:
Class Warning Label:
Aperture Label:
Certification Label:
Exposure Duration:
Skin MPE:
Minimum OD (diffuse viewing at 1 m):
Diffuse reflection NHZ:
Focal Length: (mm)
Single Mode - mode field diameter: (um)
Multimode Numerical Aperture:
Revision 05/27/2015
Available Laser Safety Eye Wear Information:
Manufacturer:
Model:
Manufacturer:
Model:
Manufacturer:
Model:
OD
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OD
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OD
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Control Measures
Location (Indoors / Outdoors)
# of Lasers in Use:
Area Warning Sign:
Entryway Interlocks:
Access Warning Lights:
Barrier at Entryway:
Laboratory Windows:
Eyewear available:
Panic Button:
Unattended Operation:
Beam Path Enclosure:
Stray Beam / Reflections Limited by:
Hazard Warning Labels on:
Operating Procedures:
Alignment Procedure:
Trained Personnel:
Other Beam Controls:
Approved Alternate Controls:
Electrical Hazard During Operation :
Adequate controls of electrical hazards:
Electrical Hazard During Alignment or Maintenance:
Adequate controls of electrical hazards:
Other non-beam hazards:
Conditions of Approval:
Grayed areas are for EH&S Use Only
Return Completed Form to:
David Schoep, Radiation Safety Manager ([email protected] / (575) 646-1023
NMSU EH&S / MSC 3578
Revision 05/27/2015
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