Permission To Work Alone Form
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2PERMISSION TO WORK ALONE FORM - GUIDELINES
Scope:
This applies to any work that will be performed alone involving hazardous materials, procedures or equipment.
Rationale:
According to CMU's Chemical Hygiene Plan, it is up to each Principal Investigator (PI) to determine what level of hazard
is permissible for working alone in their group. Some groups do not allow any working alone at all, while others allow
varying degrees of working alone, depending on the specific hazard, the training and experience of the person working,
and the safeguards that are in place. Working alone with pyrophorics (substances that ignite spontaneously upon
contact with air) is always prohibited. Working alone with machine shop equipment (lathes, band saws, etc.) is always
prohibited. The form can be written once in general terms and applies to any time and place the individual works alone.
It assures the PI that workers won’t undertake unapproved hazardous processes alone and it assures the worker that the
processes they are performing alone have been assessed for safety.
“Hazardous Materials” are defined by the hazards indicated on the Safety Data Sheets, product labels or pictograms. A
material is considered “hazardous” if it is classified as one or more of the following:
1. Flammable/Combustible
4. Compressed Gas
7. Acutely Toxic/Poisonous
2. Oxidizing
5. Corrosive
8. Carcinogenic/Organ Affecting
3. Explosive/Reactive
6. Toxic to Aquatic Life
9. Irritant
If the chemical has a National Fire Protection Association “safety diamond” on it, a number greater than 0 in any
diamond identifies it as a hazardous material. If there is any level hazard associated with the material and a person will
work alone with it, it is necessary to have the form on file.
Section I:
SHORT DESCRIPTION OF WORK TO BE DONE:
Please describe the specific type of work to be done (such as synthesis of X compounds, preparation of X samples,
running of X equipment, conducting X type of experiment).
HAZARDS ASSOCIATED WITH THE WORK:
Please indicate the hazards associated with your materials, procedures or equipment. If “other” is checked, please
indicate the specific hazard(s).
Section II:
DURATION OF PERMISSION:
Please indicate the duration of the permission. This can be for a specified duration (such as a semester or a year if a
known endpoint has been established), or indefinitely (such as the duration of studies, duration of employment or
duration of the project, etc.).
PROCEDURES IMPLEMENTED TO MITIGATE THE RISKS FROM THE HAZARDS ABOVE:
Please specify the measures in place that will protect the person working alone. These can be engineering controls
(such as fume hoods), personal protective equipment (gloves, lab coat, safety glasses, goggles, etc.) or administrative
controls (such as PHS protocols, procedures). The safeguards should match the level of risk associated with the hazard of
working alone, and cover possible scenarios. Please specify what measures will be taken beyond what would normally
be done if someone else was in the room. If necessary, additional sheets can be attached. Don’t leave this blank!
PLAN IF WORKER CANNOT SUMMON HELP:
Please indicate the strategies you will use to address how an outside person will know that the worker needs help
should they become incapacitated and cannot call for help themselves. It may mean letting someone else know when
they will be working alone (day and duration) and having a check in within that period, whether an in-person physical
check, or a remote mobile check, or using an app that requires the worker to respond periodically. If a check in is
missed, the outside person knows to call for help. Physical checks are preferred, but the other means are acceptable.
EH&S has prepared a Fact Sheet, “Best Practices for Working Alone.”
Please submit forms to EH&S for review. The PI signature in Section II must match the PI name in Section I.
Revised 5/2016
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