Forms

Mobile Elevated Work Platform

• Mobile Elevated Work Platform Pre-Start Inspection Checklist
• Mobile Elevated Work Platform Occupant Training Checklist
• Mobile Elevated Work Platform Exit Permit
• Mobile Elevated Work Platform Daily JHA & Rescue Plan

Emergency Procedures

Administered by UVA Emergency Management

• Emergency Procedures Poster

Contractor Safety Acknowledgement

• Appendix C - Contractor Acknowledgement

Fall Protection

• Fall Protection Program
  • Fall Protection Checklist
  • Fall Protection JHA and Rescue Plan

Inspections

Correct inspection procedures can prevent incidents, injury/illness, and/or property/equipment damage.

• Electrical Cord Inspection
• Ladder Inspection
• Tool Inspection

Job Hazard Analysis

• Job Hazard Analysis (JHA)
  • Sample of a completed JHA
• Non-permit Required Confined Space Pre-entry Hazard Evaluation Form

Permits

Permits are an essential tool for assuring safety during potentially hazardous work activities. The process guides the supervisor and employees through a systematic evaluation of the task to be completed.

• Confined Space Entry Permit
• Energized Electrical Work Permit
  • Energized Electrical Work Permit and PPE Flow Chart
• UVA Hot Work Permit

Respirator Forms

If you have questions about your respirator or would like to request sampling or training, email FM-OHS@virginia.edu.

Learn how to don (put on) and doff (take off) an N95 respirator.

• Medical Evaluation Questionnaire
• KN95 Respirator Voluntary Use Form
• Non-Routine Respirator Use Plan
• OSHA Respirator Medical Evaluation Questionnaire
• Respirator Fit Test and Training
• Respiratory Protection Program Exit Form
• Respirator Use Information
• Respirator Voluntary Use Form
• Worksite-Specific Procedure for Voluntary Use of Filtering Facepiece Respirator
• Worksite-Specific Procedure for Use of Respiratory Protection

Safety Shoe Request

• Safety Shoe Feedback Form
• Safety Shoe Request Form
• Safety Shoe Program
• Personal Protective Equipment (PPE) FAQs

Sampling

Sampling and analysis is conducted on jobsites and at regular work tasks by an occupational health and safety professional to look for physical stressors, biological hazards and chemicals to ensure workplace safety. Email FM-OHS@virginia.edu if you have questions about this process.

• Air Monitoring Request
• Noise Monitoring Request

Training

See OHS Training Courses

• Training Course Request

Workers Comp, Incident, and Near Miss

• Near Miss Report Form – Only use this form for incidents that did not result in injury. A near miss event is defined as an unintentional in nature, unsafe occurrence that could have resulted in an injury or fatality. Only a fortunate break in the chain of events prevented an injury, fatality, or damage.
• Workers’ Compensation/Accident-Injury Reporting Portal – includes online reporting form, checklists for employees/supervisors and quick facts.