Table of Contents Appendix 1 - Employer's Report of Injury to Employee Appendix 2 - Emergency Telephone Numbers Appendix 3 - Supervisor's Accident Report Form Appendix 4 - Accident Report Form Appendix 5 - Fire and Safety Exit Drill Report Appendix 6 - Industrial Hygiene Assistance Request Form Appendix 7 - Application for Use of Open Flame Devices Appendix 8 - Notice to Remove Open Flame Device Appendix 9 - 2nd Notice to Remove Open Flame Device Appendix 10 - A.R. Smith Department of Chemistry Appendix to the Chemical Hygiene Plan

Appendix 1 - Employer's Report of Injury to Employee

A copy of I.C. Form 19 can be obtained from the University's Electronic Forms Web Site.

Appendix 2 - Emergency Telephone Numbers

Appalachian State University
Emergency Numbers
Listed in Priority Order

NUMBER	AGENCY
9-911	FIRE DEPARTMENT AMBULANCE BOONE POLICE
8000 (EMERGENCY) 2150 (NON-EMERGENCY)	UNIVERSITY POLICE
262-4007	SAFETY & WORKERS' COMPENSATION OFFICE
262-3100	STUDENT HEALTH SERVICES
262-4100	WATAUGA MEDICAL CENTER
264-4235	WATAUGA CO. EMERGENCY MANAGEMENT COORDINATOR (Local Emergency Operations Center)
800-846-6946 (EMERGENCY)	POISON CONTROL: CAROLINA MEDICAL CENTER, CHARLOTTE, NC

Appendix 3 - Supervisor's Accident Report Form

A copy of the Supervisor's Accident Report Form can be obtained from the University's Electronic Forms Web Site.

Appendix 4 - Accident Report Form

A copy of the Accident Report Form can be obtained from the University's Electronic Forms Web Site.

Appendix 5 - Fire and Safety Exit Drill Report

A copy of the Fire and Safety Exit Drill Report can be obtained from the University's Electronic Forms Web Site.

Appendix 6 - Industrial Hygiene Assistance Request Form

A copy of the Industrial Hygiene Assistance Request Form can be obtained from the University's Electronic Forms Web Site.

Appendix 7 - Application for Use of Open Flame Devices

Download Application for Use of Open Flame Devices

Appendix 8 - Notice to Remove Open Flame Device

Download Notice to Remove Open Flame Device

Appendix 9 - 2nd Notice to Remove Open Flame Device

Download 2nd Notice to Remove Open Flame Device

Appendix 10 - A.R. Smith Department of Chemistry Appendix to the Chemical Hygiene Plan

1. Every employee shall follow the current safety rules for the A. R. Smith Department of Chemistry.
2. Every employee shall be provided with the most current edition of the American Chemical Society publications 1 , 2 , "Safety in Academic Chemistry Laboratories," Volumes 1 & 2. Guidance for specific chemicals and operations is provided in these publications. It is the employee's responsibility to become familiar with information relevant to their lab operations in these publications.
3. Every employee shall receive training as required in the most current edition of the University Chemical Hygiene Plan. The training procedure is outlined in the A.R. Smith Department of Chemistry Chemical Hygiene Training Checklist.
   1. American Chemical Society Joint Board - Council Committee on Chemical Safety. Safety in Academic Chemistry Laboratories: Accident Prevention for College and University Students, 7th ed.; American Chemical Society: Washington, DC , 2003.
   2. American Chemical Society Joint Board - Council Committee on Chemical Safety. Safety in Academic Chemistry Laboratories: Accident Prevention for Faculty and Administrators, 7th ed.; American Chemical Society: Washington, DC , 2003.

Revised 11/4/2004

Last modified 05/08/2009 09:59:41 AM by Matt McNaney