Employee Name:	Department:
PI/Manager/Area Supervisor:	Date:

This document needs to be completed upon employment and at any time when the employee’s job duties change. A change in job duties may expose the employee to new risks within the workplace. Please note that some training is regulatory driven and some is optional. This optional training will provide additional subject matter knowledge.

If the employee does work in several categories (work in a lab, uses power tools, and drives a forklift) review each category below to ensure that the employee is obtaining the appropriate training.

After you have checked the box(s) that apply to the employee, click submit (agsafe@ksu.edu) at the end of this document. You will be provided an e-mail with linkages to the required and optional training for your employee that supplements the departmental training requirements.

Hazard Assessment (The EH&S Office is available to assist in completing workplace hazard assessments.)
☐	Risk Assessment: Assess the hazard(s), specifically work practices and the work conditions
☐	Job-Specific Risk Assessments: Job Safety Analysis (JSA) ☐ ; Personal Protective Equipment (PPE) ☐
☐	Risk Priority: Rank the hazards based on individuals exposed, likelihood of occurrence, severity, etc.
☐	Risk Mitigation: Actions focused on eliminating or reducing the risk
Laboratory/Chemical Safety
☐	Lab Setting: Use hazardous materials in the laboratory (this includes oils, solvents, paints, gases, etc.)
☐	Non-Lab Setting: Use hazardous materials in a workplace other than a laboratory (field sites, shops, etc.)
☐	Waste Management: Generate hazardous waste in the course of work
☐	Ship or Transport: Prepare to ship or transport any quantity of hazardous materials
☐	Pesticide Use: Use or supervise those that use agricultural pesticides
☐	Maintenance or Service: Enter laboratory to maintain or service equipment
☐	Emergency Response: Train in spill clean-up procedures
Biological Safety and Bloodborne Pathogens
☐	Bloodborne Pathogens: Risk of exposure to blood and bodily fluids
☐	BSL Containment: Use or supervise a laboratory requiring containment: BSL1 ☐ ; BSL2 ☐ ; BLS3 ☐
☐	Select Agents: Work with select agents
☐	Sharps: Use and disposal in approved sharps containers
☐	Maintenance or Service: Enter BLS1, BLS2, or BLS3 laboratory to maintain or service equipment
Animal Handling
☐	Animal Behavior: Understand behavior to avoid accidents
☐	Animal Handling: Come in physical contact with any animal species and their bedding or holding areas
☐	Asthma and Allergies: Risk of exposure to danger, fur, body waste and saliva
☐	Work Conditions: Ventilation, traction, proper access for animals and people, escape routes for handlers
Motorized Equipment
☐	Mobile Aerial Lifts: Operate a mobile aerial lift, scissor lift, boom lift, etc.
☐	Forklift: Operate a forklift, battery powered pallet jack, or other material handling equipment
☐	Skid-Steer Loader: Operate a skid-steer loader
☐	ATV Vehicles: Operate an ATV vehicle
☐	Agricultural Equipment: Operate a tractor, combine, backhoe, baler, farm truck, mower, etc.
☐	Unmanned Aerial Vehicles (UAV): Use of UAVs in the conduct of work

Specialized Tasks
☐	Excavation: Trenching (digging below four feet below grade)
☐	Fall Protection: Work or supervise those that perform elevated work greater than four feet above work area surface
☐	Confined Space: Entry or supervise those who work in confined spaces, e.g., tanks, grain bins, animal waste areas
☐	Hot Work: Weld, cut or solder with a torch, braze, or grind
☐	Ladder Work: Use or supervise those who work on portable ladders
☐	Lock and Tag Out: LOTO hazardous energy sources
☐	Electrical Safety: Exposure to electrical hazards
☐	Power Tool Safety: Use or supervise the use of electrical powered tools
☐	Machine Guarding: Use or supervise the use of industrial equipment
☐	Compressed Gases: Work with or use compressed gases
☐	Asbestos: Conduct work that could disturb asbestos containing materials
☐	Fume Hood: Conduct work in a chemical fume hood
☐	Fire Extinguisher: Use portable fire extinguisher for incipient fires
☐	Human Factors: Tools and equipment ergonomically designed to conform to the worker
Personal Safety
☐	Eye Protection: The potential for chemical splash or airborne materials requires the use of goggles
☐	Hearing Protection: Work in an environment with excessive noise greater than 85dBA TWA
☐	Respirators: Airborne work exposure requires the use of a respirator (N95, half-face, PAPR, etc.)
☐	Gloves: Work exposure requires the use of gloves selected based on their correct type and protection level
☐	Coveralls: Work requires the donning of chemical resistive coveralls
☐	Personal Protective Equipment: Select/use hard hats, protective shoes, gloves eyewear, face shields, outer garments
☐	Safe Operating Procedures (SOPs): Developed for the job and the work this employee will be doing
☐	Medical Surveillance: Medically cleared to wear a respirator and work in a hazardous environment
Physical Demand Criteria
☐	Work Acclimatization: Adapt to the new job physical demands and environmental conditions
☐	Lifting, Carrying, Pushing, and Pulling: Light (10-20 lbs.) ☐ ; Medium (25-50 lbs.) ☐ ; Heavy (50-100 lbs.) ☐
☐	Thermal Stress: Work in environments where high heat or cold is present
☐	Elevated Work: Climb and work at elevation
☐	Computer Use: Use a computer or other activity requiring a high degree of repetitive motion
☐	Vehicles: Use of state-owned vehicles
Environmental
☐	Spill Prevention and Countermeasure Plan (SPCC): Responsibilities related to the storage of fuels/oils
☐	Pollution Collection Devices (Bag Houses/Dust Collectors): Taking opacity readings
☐	Waste Management: Manage the disposal hazardous waste
Radiation Safety
☐	Gauge User: Work with gauges that have a radioactive source
☐	Radiation Safety: Work with radioactive materials
☐	X-Ray Safety: Work with X-Ray producing devices

☐ Submit	☐ Clear