Safety, Health & Wellbeing
Phone: 6488 3938 Fax: 6488 1179
Email: safety@uwa.edu.au
Web: http://www.safety.uwa.edu.au
Laser Protocol Form
Supervisor (Licensee):
Licence Number:
School / Section:
Title of project:
Licence Expiry date:
Date of commencement:
Duration:
User Details
Names of Users
Laser equipment to be used
Manufacturer
Model
S/N
Attended Laser Safety course
Yes / No
Class
Description Wavelength/s
Power, Frequency/Energy/Time
Room
Warning signs and Lights (3B and 4 lasers) must conform to AS/NZ 2211
Room warning signs
Low power alignment procedure
Room warning light LASER ON
Machine warning light LASER ON
Door interlock
Machine sign
Goggles (correct type and quantity)
Shutter label
Shutter
Key switch (kept in secure location)
Shielding, beam stops
Beam stops
Secured to table
Beam enclosure (fire proof)
Beam enclosure - interlocked
Records, training and working rules
All users trained
Safety induction for lasers carried out
(records)
Safety and Working procedures
Read by all users (induction process)
Mounted well below eye level
Windows blinds
Room lighting
Segregated laser areas
(for separate lasers)
Supervision of users (by licensee)
Registration (laser noted on registration)
Licensing
Accident reports
Laser Protocol Form
Published: March 2014
Version 2.0
Authorised by Radiation Safety Committee
Review: March 2019
Page 1 of 2
This document is uncontrolled when printed. The current version is available on the Safety, Health & Wellbeing website
Safety, Health & Wellbeing
Phone: 6488 3938 Fax: 6488 1179
Email: safety@uwa.edu.au
Web: http://www.safety.uwa.edu.au
DESCRIPTION OF THE PROCEDURE
Include information on:
Frequency, Pulse energy, Power, Wavelength
For Partially Enclosed units:
 Description of shielding and operational Aspects
 Description of any manual beam alignment to be carried out
1. Signature of Applicant:
Date:
2. Licensee responsible for the project
3. School/Section Laser Safety Officer approval
Signature:
Signature:
Print Name:
Date:
4. Approved by SH&W
Date:
(SLSO should forward completed form to SH&W
for approval)
Safety, Health & Wellbeing Use Only
Approval Number:
Expires:
Signature:
Date:
Subject to the following conditions:
Laser Protocol Form
Published: March 2014
Version 2.0
Authorised by Radiation Safety Committee
Review: March 2019
Page 2 of 2
This document is uncontrolled when printed. The current version is available on the Safety, Health & Wellbeing website