Laser Hazard Assessment Form
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1
2Laser Hazard Assessment Form
Iowa State University Environmental Health & Safety
Ames Laboratory Environment, Safety, Health & Assurance
Laser Supervisor:_______________
Group Leader: _______________________
Laser Location: _______________
Phone Number: ____________________________
**********************************************************************************
Manufacturer:_____________________ Type: ________________________________________
Model: _____________________
Serial Number: ____________ ISU/AL Prop #:____________
**********************************************************************************
Minimum Wavelength: ____________________
Maximum Wavelength: ___________________
Pulse Mode:
(
) Continuous Wave – go to#1
(
) Single Pulse – go to #2
(
) Multiple Pulse – go to #3
1) Average Power (watts): __________________________
2) Energy Per Pulse: __________ joules
Pulse width: __________ sec.
3) Energy Per Pulse: _____ joules
Pulse width: _____ sec.
Pulse Rep. Freq: _____ Hz
Beam Profile: ( ) Circular ( ) Elliptical
Beam Distribution: ( ) Gaussian ( ) Top Hat
Divergence: _____ mrad
Diameter at Waist: _____ cm
Aperture to Waist Distance: ____ cm
Aperture Diameter: _____ cm
Extended Source Size: _____ cm (for Top Hat distribution, collect for X and Y)
******************************************************************************************
PERSONNEL & ADMINISTRATIVE CONTROLS:
1) Authorized user list current?
___ Yes ___ No ___ N/A
alignment
2) Standard Operating Procedures for operation &
?
___ Yes ___ No ___ N/A
3) Authorized users had Laser Safety training through Ames Laboratory?
___ Yes ___ No ___ N/A
4) Group-specific training conducted and documented?
___ Yes ___ No ___ N/A
6) Buddy system in place?
___ Yes ___ No ___ N/A
7) Appropriate warning signs present?
___ Yes ___ No ___ N/A
Ames Lab ONLY
8) Readiness Review number (
): ________________________________________________
COMMENTS:______________________________________________________________________________
B.
SYSTEM CONTROLS
1) Beam attenuator/shutter operational?
___ Yes ___ No ___ N/A
2) Protective housing interlocks work?
___ Yes ___ No ___ N/A
3) Warning lights and/or alarms work?
___ Yes ___ No ___ N/A
Class IV ONLY
4) Key control system for main power supply (
)?
___ Yes ___ No ___ N/A
Class IV ONLY
5) "Panic button" identified and operable (
)?
___ Yes ___ No ___ N/A
6) Room door interlocked with the laser system?
___ Yes ___ No ___ N/A
Class IV ONLY
7) Key control system for interlock override switch? (
)?
___ Yes ___ No ___ N/A
Class IV ONLY
8) Interlock lights operational (
)?
___ Yes ___ No ___ N/A
COMMENTS: _____________________________________________________________________________
________________________________________________
Form 10202.049
ESH&A 294-2153
Revision 0, Effective Date 03/01/13
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