A Self- Assessment Safety Checklist Form printable pdf download

A Self- Assessment Safety Checklist Form

ISEF Guidelines for Biosafety Level 1

Laboratory Facilities & Operations

A Self- Assessment Safety Checklist

This form is intended to aid in assessing a laboratory as appropriate to do BSL 1 studies in locations such

as water testing facilities, high schools or colleges teaching introductory microbiology classes. The

following checklist is based on the Biosafety Level 1 section of “Laboratory Biosafety Manual”, 3

edition,

World Health Organization, 2004.

Facility Name _________________________________

Room # __________

Address

_________________________________

 Name of Laboratory Supervisor/Teacher_________________________

o This person must be educated, trained and qualified to supervise microbiological

projects and maintain the criteria below.

o Qualifications: (List or attach additional sheet if necessary. Qualifications should

include general training in microbiology or a related science)

______________________________________________________________

___________________________________

I attest that I have the qualifications listed above (or attached).

I attest that there will be direct supervision of students when they are in the laboratory.

Laboratory Supervisor/Teacher Signature___________________________________

Date of signature __________________________



Name of Responsible Administrator _____________________________

I attest that this laboratory is a BSL 1 facility and complies with all procedures listed on

this form and that the person named above is educated, trained and qualified to

supervise microbiological projects and maintain the criterion below.

Administrator Signature

________________________________________

Title

____________________________________________

Date of Signature

_________________________

A Self- Assessment Safety Checklist Form