Laboratory Equipment Check-Out Form
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1For the Lab Coordinator use only:
Ref #: ______________________
Date: ____ / ____ / ________
Laboratory Equipment Check-Out Form
Faculty supervisor name:
þÿ<please_select>
End user (student) name:
þÿ
Contact email:
@ lakeheadu.ca
þÿ
Contact phone with area code, as 123-456-7890:
þÿ807-343-0000
Equipment used (check all applicable):
on campus
off campus
Check-out: Date (yy-mm-dd):
Time (hh:mm):
þÿ03-09-2014
þÿ09:30
Return:
Date (yy-mm-dd):
Time (hh:mm):
þÿ01-12-1999
þÿ16:30
Item
Tag #
Description
Qty.
1
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9
10
I hereby confirm that all equipment listed above is in good working order. I acknowledge that I have
been trained on the proper usage of the equipment and I am aware of all the measures required for the safe
use of this equipment.
This form – while held by the Laboratory Coordinator - constitutes proof that the equipment is under
my responsibility and in my possession. This form will be returned to me upon me returning the equipment, in
good working order, to the Laboratory Coordinator.
End user signature: ___________________
Date: _____________
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Parent category: Life