Application for the Possession and Use of Lasers in Basic Research

Application for the Possession and Use of Lasers in Basic Research

Applicant

Authorized User (AU)	Laser Safety Supervisor (if not AU)
Name:	Last First
Phone/Fax:
Campus Address:
Department/School:
Email Address:

Scope of this Application

Type: New Authorization Amendment Renewal with requested changes to current authorization

Laser Equipment (if more than three please submit a separate sheet for each additional laser)

	Laser #1	Laser #2	Laser #3
Type
Class (if known)
Manufacturer
Model #
Serial #
Inventory #
Excitation Mechanism
Time Dependent Properties
Power in Watts (for continuous wave lasers)
Max Energy (for pulsed)
Max Pulse Frequency
Minimum Pulse Duration
Wavelength

Facilities

Room	Building	Laser(s) Located in Facility

Personnel: Prepare a list of personnel who may be exposed to laser radiation in conjunction with this protocol. New personnel must register with the Laser Safety Office and successfully complete the laser safety training course before they may work independently with laser equipment. Contact the Laser Safety Officer for further information.

Name (last, first, MI)	Social Security Number	Title/Duties

Standard Terms and Conditions

Following are the standard Terms and Conditions assigned to each Authorization issued by the University of Maryland Laser Safety Officer. Failure to comply fully with these Terms and Conditions may result in the suspension, alteration or revocation of this Authorization.

The Authorized User named herein agrees to comply with all recommendations, policies and procedures promulgated and published by the University's Laser Safety Officer.
The Authorized User signifies he/she has read and will abide by the University of Maryland's policies and procedures governing the use of laser equipment.
The Authorized User shall maintain inventory records for all laser equipment as may be required by the University's Laser Safety Officer.
The Authorized User is responsible for providing all personnel under his/her supervision, instruction in the basic standards for laser safety in accordance with laser Safety Program Manual.
All Class 3b and 4 lasers in the possession of the Authorized User must be registered with the Laser Safety Officer.
Registered laser equipment may only be present at locations specified and approved in the Authorization.
A copy of the current Authorization, all related amendments and correspondence and UMB policies shall be kept as part of the Authorized User's permanent records and shall be available for examination by any interested person; including employees, students, or staff.
All individuals using lasers under this authorization must attend laser safety training at their earliest convenience if they have not already done so.
Additional Terms and Conditions may be added to this Authorization at any time.

Facility Registration

Please complete the Facility Registration Form for each laser facility. Please identify locations for the laser, control panel, beam stops, barriers or curtains, interlocks, etc. Fax the form to the Laser Safety Officer.

Standard Operating Procedures

Please submit a copy(s) of your formal written description of the safety and administrative procedures to be used for each specific laser operation(s).

Statement of Consent

The Applicant and Department Head certify that to the best of their knowledge the information contained in this application is complete and correct. The Applicant agrees to abide by the University of Maryland's regulations governing the use of laser devices. Further, the Applicant acknowledges that failure to comply fully with said regulations may result in immediate revocation of authorization.

Read and Acknowledged Date: 04/03/06