Permit Request • CampusOptics

For all research proposals involving the use of lasers, complete, sign and submit this form to Risk Management Services for review by the Laser Safety Officer or the Radiation Safety Committee as applicable.

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Principal Investigator

Title* Required

Department* Required

Laboratory Information

Laboratory(s) where the laser(s) will be used* Required

1. Additional names of person(s) using laser under the PI's license

2. Additional names of person(s) using laser under the PI's license

3. Additional names of person(s) using laser under the PI's license

Laser Information

Briefly describe use of lasers* Required

Safety Precautions

Mark all safety precautions that will be used for this research project* Required

Posting of warning signs
Appropriate Personal Protective Equipment utilized
All authorized persons trained in laser safety
Restrict access to controlled areas
Identify laser type(s) to be used

Training Information

1. Name

1. Date of Completion

2. Name

2. Date of Completion

3. Name

3. Date of Completion

4. Name

4. Date of Completion

Protocol: Attach additional pages per laser as needed.

Brief description of procedures* Required

Detailed safety precautions* Required

Briefly describe the work to be performed with the laser.

Wavelength Range* Required

Emission Duration* Required

Maximum Power or Energy* Required

Describe the safety training* Required

Describe any special hazards and measures for those hazards* Required

What kind of facility* Required

If other, please describe

Do you have standard operating procedures for general operation, maintenance, and service procedures (required for Class 3b and 4)* Required

If yes, please describe

Veterinary medicine or surgical applications to animals* Required

If yes, please explain

Applicant Acknowledgement and Agreement

Principal Investigator Electronic Signature* Required

Date* Required

Comments

FOR RADIATION SAFETY COMMITTEE USE ONLY

Decision

Approval Date

Approval name and title* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files