------------------------- -- ------------ -- --------------------- -- ---------- -------------
                                                                                   Requisition
                                                                                   No./Date

                                                                                   

                                                                                   

  Employee/Guest Name          Life/Guest                               Start Date 
                               Number                                              

  Physics Department           PO                                       510        

  Department/Division          Dept./Div.                               Bldg.      
                               Code                                     Number     

                                               Mike Zarcone x5890 /                
                                               Ron Gill x3987                      

  Supervisor/Sponsor/Ext.                      ESH Coordinator/Ext.                

  Mike Zarcone x5890/2585                      Joe Vignola x3846 /                 
                                               Paul Bergh x5992                    

  Training Coordinator/Ext.                    Facility Support                    
                                               Representative/Ext.                 

                                                                                   
  ------------------------- -- ------------ -- --------------------- -- ---------- -------------

Administration

+-----------------------------------+-----------------------------------+
| 1\. General orientation/check-in  |                                   |
| at Human Resources\               |                                   |
| or Facility User\'s Office        |                                   |
| Completed.                        |                                   |
+-----------------------------------+-----------------------------------+
|                                   | Human Resources Signature         |
+-----------------------------------+-----------------------------------+
| 2\. BNL identification/vehicle    |                                   |
| pass issued.                      |                                   |
+-----------------------------------+-----------------------------------+
|                                   | Security Signature                |
+-----------------------------------+-----------------------------------+
| 3\. ESH Coordinator\'s briefing   |                                   |
| completed.                        |                                   |
+-----------------------------------+-----------------------------------+
|                                   | ESH Coordinator\'s Signature      |
+-----------------------------------+-----------------------------------+
| 4\. Facility Support              |                                   |
| Representative\'s briefing        |                                   |
| completed.                        |                                   |
+-----------------------------------+-----------------------------------+
|                                   | Facility Support                  |
|                                   | Representative\'s Signature       |
+-----------------------------------+-----------------------------------+
| 5\. [Supervisor\'s                | [Training Coordinator             |
| Section]{.underline}              | Section]{.underline}              |
+-----------------------------------+-----------------------------------+
| a\. Will Radiation Dosimetry be   | d\. Job Training Assessment (JTA) |
| issued? \                         | Code(s) to which employee/guests  |
| yes no                            | should be linked:                 |
|                                   |                                   |
|                                   | GE-53E                            |
|                                   |                                   |
|                                   | PO-01                             |
+-----------------------------------+-----------------------------------+
| b\. Will individual be working in |                                   |
| areas belonging to\               |                                   |
| another department? \             |                                   |
| yes no                            |                                   |
+-----------------------------------+-----------------------------------+
| c\. If yes, list working          |                                   |
| Department, Location, and Contact |                                   |
| Name.                             |                                   |
|                                   |                                   |
|                                   |                                   |
|                                   |                                   |
| e\. Supervisor\'s briefing on     |                                   |
| job- and work- location-specific\ |                                   |
| hazards completed.                |                                   |
+-----------------------------------+-----------------------------------+
|                                   | JTA Codes for Employee/Guest      |
|                                   |                                   |
|                                   | Training Coordinator briefing on  |
|                                   | training requirements.            |
+-----------------------------------+-----------------------------------+
| Supervisor\'s Signature           | Training Coordinator\'s Signature |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+

General Employee/Radiological Training

<table>
<colgroup>
<col style="width: 25%" />
<col style="width: 23%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 10%" />
<col style="width: 2%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"></td>
<td></td>
<td colspan="3">Supervisor's<br />
Initials</td>
<td></td>
<td>Date<br />
Scheduled</td>
<td></td>
<td>Instructor's<br />
Initials</td>
</tr>
<tr class="even">
<td colspan="2">General Employee Training or Site Orientation for
Guests</td>
<td></td>
<td colspan="2">X</td>
<td>Required<br />
for all</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Hazard Communication</td>
<td></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Or</td>
<td></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Laboratory Standard</td>
<td></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Or</td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="2">Neither Hazard Communication nor Laboratory Standard is
required.</td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="8"><p>Supervisor's Signature</p>
<p>Date</p></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="5"><p>General Employee Radiological
Training<br />
or</p>
<p>Radiological Worker I (Prerequisite for the following)</p>
<p>Contamination/High Contamination<br />
Bench-top Dispersibles<br />
or</p></td>
<td rowspan="2"></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>No Radiological training is required</td>
<td colspan="3"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9">Supervisor's Signature Date</td>
</tr>
<tr class="even">
<td colspan="4">Previous BNL Safety training is valid. (Indicate valid
courses and completion dates in appropriate spaces.)</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Training Coordinator's Signature Date</td>
<td colspan="6"></td>
</tr>
</tbody>
</table>

Additional Required Training

  ---------------- --------------------------- -------------- ------------
  Employee/Guest   Type Name                   Requisition         
  Name                                         No./Date       

  ---------------- --------------------------- -------------- ------------

Schedules and course information is available at http://training.bnl.gov
or from your Training Coordinator.

+--------------------------------------------+--------+--------+-------+
| **Common Course Requirements**             | **Su   | *      | **C   |
|                                            | pervis | *Date\ | omple |
|                                            | or\'s\ | Sched  | tion\ |
|                                            | Init   | uled** | D     |
|                                            | ials** |        | ate** |
+--------------------------------------------+--------+--------+-------+
| Emergency Planning and Response (for       | X      | \*\*   |       |
| Employees Only)                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Environmental Protection Training (for     | X      | \*\*   |       |
| Employees Only)                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Security Programs/Responsibilities(for     | X      | \*\*   |       |
| Employees Only)                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Cyber Security Training                    | X      | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Protecting Personally Identifiable         | # X    | \*\*   |       |
| Information (for Employees Only)           |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Hazardous Waste Generator                  |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Radioactive Waste Generator                |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Transportation of Hazardous Material       |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| HAZWOPER (Specify: 24 hour, 40 hour, 8     |        |        |       |
| hour Supervisor)                           |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Basic Electrical Safety                    |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Electrical Safety 1                        |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Lock-out/Tag-Out Affected Worker           |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Lock-out/Tag-Out Authorized Worker         |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Cardiopulmonary Resuscitation              |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Back Safety                                |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Forklift Operator/Practical, Note: medical |        | \*     |       |
| exam prerequisite                          |        | \*/Pra |       |
|                                            |        | ctical |       |
+--------------------------------------------+--------+--------+-------+
| Crane Operator/Basic Rigging/Practical,    |        | \*     |       |
| Note: medical exam prerequisite            |        | \*/Pra |       |
|                                            |        | ctical |       |
+--------------------------------------------+--------+--------+-------+
| Aerial Lift                                |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Fall Protection                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Noise and Hearing Conservation, Note:      |        | \*\*   |       |
| medical exam prerequisite                  |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Bloodborne Pathogens, Note: medical exam   |        | \*\*   |       |
| prerequisite                               |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Regulated Medical Waste Management         |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Respirator Training Note: Requires Fit     |        | \*\*   |       |
| Test and medical exam prerequisite         |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Compressed Gas Safety                      |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Cryogen Safety                             |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Laser Safety, Note: medical exam           |        | \*\*   |       |
| prerequisite                               |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Confined Space Entry                       |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Oxygen Deficiency Hazard                   |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Lead in the Workplace                      |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Static Magnetic Fields                     |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Fire Extinguisher Training                 |        | \*\*   |       |
+--------------------------------------------+--------+--------+-------+
| Video Display Terminal and Ergonomics      |        |        |       |
| Safety                                     |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Machine Shop Safety                        |        |        |       |
+--------------------------------------------+--------+--------+-------+
| Lyme Disease and Tick/Chigger Bite         |        | \*\*   |       |
| Prevention                                 |        |        |       |
+--------------------------------------------+--------+--------+-------+
|                                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
| **Departmental and Job Requirements --     |        |        |       |
| Access, Procedure, and On-the-job Training |        |        |       |
| Needs**                                    |        |        |       |
+--------------------------------------------+--------+--------+-------+
|                                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
|                                            |        |        |       |
+--------------------------------------------+--------+--------+-------+
|                                            |        |        |       |
+--------------------------------------------+--------+--------+-------+

\*\* Web Course available at http://training.bnl.gov

**When the activities have been completed, return this form to your
Training Coordinator.**