User Information Form
Date:
For Center Use Only:
Proposal No.:
Date Received:
Last Name:
First Name, Middle Initial:
Organization:
Title:
Department:
Street Address:
State:
Zip Code:
Telephone:
FAX:
Email:
Project Title (The project must be approved before permission
will be granted to use any instrument.):
Proposal No. (if known):
Principal Investigator(s):
List instruments to be used:
Need Training
(Y/N)?
Billing Contact:
Title:
Authorized Signature:
Limit of Charges (if
applicable):
Last Training
Date:
Date:
Expiration Date:
Center for Integrative Nanotechnology Sciences
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User Information Form: Rev 16 January 2014
Faculty Approval
The above individual will be working under my supervision
on the specified Center for Integrative Nanotechnology
Sciences (CINS) at UALR user project. I verify that the
above information regarding his/her status at our
institution is correct, and I understand that I must notify
CINS staff regarding any change in this status.
This user authorization is only for the duration of the
CINS project and is only for work to be conducted while
he/she is an employee/student at our institution.
Exceptions should be noted below.
I understand that it is my responsibility to secure the
return of all key(s) at the completion of his/her term at
my institution or the completion of this work, which ever
comes first. I agree to pay for all materials and
instrument charges that may be required by the current CINS
Instrument Rules and Guidelines from funds in either the
above account or other accounts under my control. I
understand that there are orientation/training fees
appropriate for each instrument, which will be charged
against the above account. Additional fees and repair costs
may be charged as per current CINS Instrument Rules and
Guidelines.
Authorizing Signature(s) of P.I.(s)
Date:
User Agreement
In addition, the User warrants that he/she has been
provided with the CINS Instrument Rules and Guidelines, as
well as UALR Safety Manuals. The User has read, understood,
and agreed to abide by the rules and safety provisions
discussed in these manuals. The User also acknowledges that
it is his/her responsibility to keep abreast of updates to
these documents. While the User will be trained in the
operation of the particular instruments required by his/her
work, the User assumes primary responsibility for his/her
personal safety. It is expected that the User will operate
all instruments and equipment in a safe and professional
manner, consistent with the operating instructions and the
laboratory rules. The User represents that his/her
knowledge of general laboratory practice is advanced enough
to permit the safe pursuit of the project in question. The
User acknowledges that the CINS at UALR is a research
enabling center. The User retains ultimate responsibility
for project progress and development, and UALR does not in
Center for Integrative Nanotechnology Sciences
Page 2 of 5
User Information Form: Rev 16 January 2014
any way warrant or assure a particular project result. The
User, by completion of this User Agreement, hereby warrants
that he/she has been given a copy of the CINS at UALR
Laboratory Safety Manual and UALR Radiation Safety Manual,
UALR Chemical Safety Manual, CINS Biological Safety Manual
and has had the opportunity to ask any questions he/she
might have about the procedures, policies, rules, and/or
guidelines of the CINS. The User has furthermore received
and understood the answers to any such questions and has
fully read and agrees with the CINS Facility Use Rules and
Guidelines.
User Name (please print clearly):
User Signature:
Date:
Center for Integrative Nanotechnology Sciences
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User Information Form: Rev 16 January 2014
User Institutional Approval
All Users (and their institutions) of the Center for
Integrative Nanotechnology Sciences (CINS) at UALR
Laboratory Facilities through the CINS Laboratory User
Research Program represent that they have read, understood,
and agreed to the terms of this “CINS Instrument Rules and
Guidelines” of CINS. The User and his/her institution
understand that his/her use of the laboratory is controlled
by the provisions of the CINS User Program through which
he/she has an approved project. Instruments are provided
only for research work in conjunction with the specific
project described in the User's currently approved CINS
project proposal. The User and his/her institution
understand that he/she is not an employee of UALR and that
UALR provides no Worker's Compensation or other Liability
Coverage for the User's benefit. The User is deemed to be
acting as a representative and employee of his/her
institution during work at the CINS Laboratory. All Users
not associated with UALR (or the University of Arkansas
System) will have their own health and accident insurance,
and the User’s home institution must carry business
liability ($1,000,000) coverage. UALR will not be
responsible for any medical expenses that the User may
incur. The User and his/her institution shall release, hold
harmless, and indemnify UALR, its officers, agents, and
employees from any and all claims, damages, costs
(including reasonable attorneys' fees) and liabilities
arising from the User's use of CINS Laboratory Facilities
other than those which result from the negligence of UALR,
its officers, agents, or employees.
(NOTE: Institutional approval must be granted by an officer
of the institution with appropriate authority, e.g. the
Vice President for Research, Dean, or Director--NOT the
Principal Investigator.) Additional fees and repair costs
may be charged as per current CINS Instrument Rules and
Guidelines.
Please Print Clearly
CINS Project No:___________________
Institution: _____________________________________
___________________
Officer: _________________________
Signature:_______________________
Center for Integrative Nanotechnology Sciences
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User Information Form: Rev 16 January 2014
Officer
Date:
Title: ______________________________
Center for Integrative Nanotechnology Sciences
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User Information Form: Rev 16 January 2014