Cabarrus Lab Safety Contract

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

High School Student Laboratory Safety Contract

This is to certify and verify that I have been instructed in and understand each of the following safety rules and procedures of this science class. I agree to follow all of the safety rules set forth in this contract. I understand that if I do not follow all the rules and safety precautions, I will not be allowed to participate in science laboratory activities. *

Student Signature

Class Period *

Safety Procedures

Check off each item discussed by your teacher: *

Use lab only when directed by the teacher and only under his/her supervision.

Follow all instructions carefully. Ask questions before you proceed.

No student may work in the laboratory without a teacher present.

Confine long hair and loose clothing.

Open-toed shoes should not be worn on scheduled laboratory days.

Never directly smell substances – waft the scent toward you when directed.

Wear personal protective equipment (goggles, gloves, aprons) when directed.

Dispose of all chemical waste properly as directed by the teacher.

Place broken glass and all disposables in appropriate designated containers

Check and recheck labels on all chemical bottles before using.

Remain at laboratory stations while performing laboratory activities.

Report any accident, incident, or unsafe situation to the teacher immediately.

Students are never permitted in the science storage room or preparation areas unless given specific permission by the teacher.

Required

Check the items below indicating that you are aware of where to locate and know the proper use of the following safety equipment: *

Fire Extinguisher

Fire Blanket

Eyewash Station

Drench Shower

Eye Protective Goggles

Sand Bucket for liquid spills

Emergency phone & number

Master Gas shut-off

Required

Check the items below indicating that you know the safety procedures for the following situations: *

Chemical spills

Eye emergency

Electrical emergency

Chemical splash to body

Fire

Cuts and bleeding

Required

Other Safety Concerns

Do you wear contact lenses? *

Yes

Do you have allergies? *

Yes

If you have allergies, please list specific allergies below

Response to Student Violations of Laboratory Safety Rules:

First Offense:
Review of rule involved; parents & student sign agreement that the rule is understood and will be followed.

Second Offense: Student is removed from current laboratory activity and given a failing grade for that lab. Parent/Guardian is contacted.

Third Offense: Student is removed from all laboratory activities for the remainder of the semester. Parent/Guardian is informed.

To the Parent: Your student will be working in the laboratory during this course. In order to ensure his/her personal safety and that of fellow classmates, it is important that the above safety procedures are followed. Failure to do so may result in your son/daughter being removed from the laboratory and given a grade of Zero on effected assignments. No student will be permitted to perform laboratory activities unless this contract is signed by both the student and parent/guardian and is on file with the teacher. Your signature on this contract below indicates that you have read this Student Safety Contract, are aware of the measures taken to ensure the safety of your son/daughter in the science laboratory, and will instruct your son/daughter to uphold his/her agreement to follow these rules and procedures in the laboratory. *

Parent/Guardian Signature

Parent/Guardian E-mail Address *

Parent/Guardian Preferred Phone Number *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Cabarrus County Schools. Report Abuse

Forms