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