Flow Cytometry After-Hours Approval Form

Flow Cytometry After-Hours Approval Form
Please read the Flow After-Hours Requirements before completing this form. Flow After-Hours Approval is valid until the end of the following November, and only if all details provided remain accurate. After-hours work should be approved by your supervisor prior to submitting this application.
Date of application*

DayMonthYear
Applicant Contact
Name*

First NameLast Name
Work Email*
zID*
Mobile*
Supervisor Contact
Name*

First NameLast Name
Email*
zID*
Buddy Contact

The nominated buddy must meet the requirements stated in the Flow After-Hours Requirements including having swipe card access to areas being accessed by the applicant
Name*

First NameLast Name
Email*
zID*
Mobile*
It is recommended to nominate a secondary buddy for situations where the primary buddy doesn't respond or isn't available
Would you like to nominate a secondary buddy?*

YesNo
Secondary Buddy Contact
Name*

First NameLast Name
Email*
zID*
Mobile*
Is this application to include working over the UNSW year-end break (Christmas shutdown)*

YesNo
Please upload existing After-Hours Approval (eg. HS703)*

Please seek After-Hours Approval from your supervisor/Head of School for working over the UNSW year-end break before completing this form
Cancelof
Do you have a medical condition that could put you at risk whilst working alone?*

YesNo
Please provide details*
Instruments and locations of after-hours work

The Flow Lab is located on Level 2 Bioscience South (E26)

Please note that you may only use instruments for which you have received training and been granted access
Select the instrument/s to be used after-hours (Instrument - Room)*

Canto - 2001CellCelector - 2001Attune - 2001Fortessa - 2001Aurora - 2001Zetasizer - 2001NanoSight - 2001Verse - 2001AcCellerator - 2015Influx - 2016Melody - 2016Aria - 2017Other
The following is a list of safety documentation you are required to read for working in the Flow Cytometry Facility
Have you read and "Declared as Read" the above safety documentation?*

YesNo
Does the work involve any of the following? (select any that apply)

Risk group 3 or higher biological agentsUse of sharpsHazardous substances (including substrates, tracers, reagents, cytotoxic drugs or nanoparticles)Any other activity with a medium to high risk rating
Are any additional activities being undertaken that are not included in Flow's established safety documentation? (please note that significant deviations are subject to Flow Lab approval)*

YesNo
Please provide SWP, RMF and/or MSDS for any additional procedures, hazardous substances or equipment*

Cancelof
Please nominate an interval for contacting your buddy (aside from the mandatory arrival and departure notification):*

0.5 hours1 hour2 hoursNAOther
Please justify*
Contacts

Please note that as part of this approval you are required to answer lab phones if and when they ring

UNSW Security Emergencies	9385 6666
UNSW Security Enquiries	9385 6000

Flow Lab Phone
E26 2001	9065 2560
Flow Lab Staff Contacts
Emma Johansson-Beves	0413 381 213
Brendan Lee	0435 779 895
Carl Power	0423 516 571

In submitting this application I agree to:
- Comply with the Flow After-Hours Requirements
- Comply with UNSW HS322 Working Alone or After-Hours Guideline
- Follow all UNSW emergency procedures including instructions in the UNSW Emergency Procedures
- Follow instructions in the SWP's and RMF's for the activities being undertaken, in particular the "Emergency Procedures" sections
- Not to deviate from the Flow Lab's established safety documentation (unless approval for deviation is granted by Flow staff)
I agree to the above*

YesNo
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