Student Key Release for Faculty Research Labs or other Restricted Space*

Student Name: ______Cell Phone # ______Room Ext: ______

Campus Housing Address:______School ID#______

Access requested for (building room numbers): ______

______

Section I – Faculty Member
I confirm that I am responsible for the Lab or other room indicated at the top of this form, and that this room is to be kept locked at all times when it is not occupied. I hereby request that the student named above be given a key so that s/he may access the lab on her/his own (i.e., when I am not there). I certify that I have trained the student in the work to be performed, the particular hazards associated with the lab or room and that I have given the student any written emergency protocols specific to working in my lab and trained the student on what to do in case of an emergency.
Hours Access is allowed: ______Duration of permission: From: ___ /___ /__ To: ___ /___ /___
Restrictions on independent work: ______
______
Supervising Faculty Signature: ______Date: ______
Faculty Name: ______Phone: ______
Faculty Member Emergency Contact Information: ______
Section II – Student
Short description of work to be done: ______
______
______
I have read the “Laboratory Working Alone and After Hours Policies” (Clark Science Center Safety Handbook: http://www.science.smith.edu/resources/safety/table_contents.html) and agree to abide by their restrictions. I agree that under no conditions will I work alone ‘after hours’ in the laboratory. I confirm that I have received training in the proper experimental and emergency procedures and understand those procedures for the work I am authorized to do independently, and I agree to follow these procedures. I agree to return the key on or before the last date of the duration of permission as stated in Section I of this agreement, and that I may be billed for any lost or unreturned key/s and/or lockset/s. I understand that working alone in a lab can be dangerous, and I accept the risks of working alone. I agree to make sure that the room is locked when I leave it if it is otherwise unoccupied.
Student Signature:______Date: ______
* Additional signatures are needed for the following restricted spaces:
Burton 202/202a, Ford 130 (Tissue Culture) - Sue Haynes:
ACF - Karen Swiecanski or Paula Portelatin:
Ford 036 (500 MHZ NMR) room - Kevin Shea:
Ford 024A (Human Tissue Lab) - Susan Voss:
Ford 032 (Plant Growth Chamber) - Carolyn Wetzel:
Ford 031 (Prokaryotic Cell Culture Lab) - Christine White-Ziegler:
Ford 121A (Fluorescence Microscopy) - Stan Scordilis:
Ford 123 (CMBS Instrumentation Room) - Steve Williams, Wen Li or Chris White-Ziegler:
Ford 225 (Radioisotope Lab) – Radiation Safety Officer (Margaret Rakas):
Ford 237 (CfP darkroom) - Stan Scordilis:
Ford 238 (CfP ultracentrifuge room) - Stan Scordilis:
Section III – Clark Science Center Environmental Health & Safety Officer
This student has completed basic laboratory safety training, “Safety in General Laboratory Operations” or other basic safety training (as appropriate) provided by the Office of Environmental Health & Safety (EH&S) for the general hazards of working in a laboratory.
Training Date: ______
EH&S Signature: ______EH&S Name Printed:______
Section IV – For Administrative Use
Building Access Hours: ______Key # (if applicable) ______
Date Access Requested: ______Key Issue Date: ______
Access Expiry Date:______Key Return Date: ______
Key Request Form #: ______

CSCStudentKeyReleaseFormv3_10-29-09.doc