The University of Chicago
Laser Safety Program
Hazard Evaluation Form
This Hazard Evaluation Form is intended to provide a form of communication between
the research community and the Office of Radiation Safety. By supplying the required
parameters listed on this form, the Engineering and Administrative Controls that need to
be in place can be defined.
The parameters listed below are required to be filled out for each and every Class 3b and
Class 4 laser or laser system.
A copy is required to be returned to The Office of Radiation Safety (fax # 2-4008).
Researcher/PI: ______________________________
Laser Lab Location and Room Number: ____________________________________
Inventory Items:
Manufacture of Unit: ________________
Laser Type: _______________________
Model Number of Unit: _______________
Serial Number of Unit: _______________
(ORS Use Only): IDNS Registration Number: ____________________
Technical Specifications:
Hazard Class: ____________
Type [Lasing Media]: __________________________
Wavelength(s) (nm): ___________________________
Output Power(s) 0: ___________________________ [Ignition Source if 0 > 0.5 W]
Beam Diameter (cm): Check One:  1/e  1/e^2
Divergence (mrad):
Check One:  1/e  1/e^2
Pulsed Laser or Laser System: Check One:  No
 Yes
IF YES, COMPLETE THE FOLLOWING:
Pulse Energy (J): ___________________
Pulse Length (s): ___________________
Repetition Rate (Hz): ________________
Pulse Time Envelope (s): _____________
Limiting Aperture [ANSI Z136.1-2000, Table 8]:
Wavelength/Time Range: _______________ Eye: ________ Skin: __________
Per ANSI Z136.1-2000 section 4.6.2.5.1 [Specification of Optical Density], the output
power and irradiance are averaged over the limiting aperture instead of the beam
diameter if the beam diameter is smaller than the limiting aperture.
Time Factors [ANSI Z136.1-2000, Table 4a]
Wavelength Range: ______________ Diffuse (s): ______ Intrabeam (s): ______
Output Irradiance (E) (W/cm^2): ____________________
Maximum Permissible Exposure (MPE) (W/cm^2): _________________
NOTE: The MPE for a repetitively pulsed laser is determined by applying three
“Rules” from ANSI Z136.1 to ensure appropriate consideration of all
photochemical and thermal effects.
Nominal Hazard Zone Associated with Unit (cm): _______________
Minimum Optical Density Required for Unit (OD): ______________
Signature of Preparer: ______________________
Name of Preparer (Print): ___________________
Date: ____________
Signature of PI/Supervisor: __________________
Date: ____________
Issued: May 6, 2009