TANDEM FACILITY USER QUESTIONNAIRE

 

 

Organization: ____________________________________________________________________

 

Contact Person: _______________________           Telephone Number: ______________________

 

Purchasing Contact: ___________________            Telephone Number: ______________________

 

Purchase Order # _____________________             Expected Run Dates: _____________________

 

 

Type of Work?          Proprietary           Non-Proprietary (Tandem Open Data)

 

 

Purpose of Use

 

SEU Testing?      Yes ___ No ___   If No, please describe____________________________________

 

Hazards                Will the following hazards or dangers be present during your experiment?

 

1.     Prior activation or contamination of your equipment or parts?                                         Yes __ No __

 

2.     Prior parts or equipment exposure to particle beams?                                                         Yes __ No __

 

3.     Equipment contains, or will you bring, radioactive sources? (List all below)                   Yes __ No __

 

4.     Dangerous voltages or Currents? (Provide working ranges)                                                Yes __ No __

 

5.     Will you bring any equipment that contains PCBs? (List all equipment                          Yes __ No __

        manufactured before 1981 for review, if necessary.)

 

6.     Mechanical Hazards?                                                                                                                Yes __ No __

 

7.     Fire or Explosion Hazards?                                                                                                       Yes __ No __

 

8.     Compressed Gases? (List type and quantity)                                                                        Yes __ No __

 

9.     Lasers? (List type and power)                                                                                                   Yes __ No __

 

10.  Biological Hazards or Wastes?                                                                                                 Yes __ No __

 

11.  Is there a potential for any environmental releases? (Gaseous, liquid, or particulate)   Yes __ No __

 

12.  Chemical Hazards or Wastes? (List types and quantities of chemicals used.)                Yes __ No __

 

13.  Other Safety Hazards Not Covered Above?                                                                          Yes __ No __

 

If you answered “yes” to any of the above questions, describe in the space below.  (Attach additional sheets if necessary.)

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________


Will you be bringing any Vacuum Chambers, Heating or Cooling Systems, or Vacuum Feed-throughs?         Yes __ No __

 

If yes, we request you submit detailed descriptions and/or drawings prior to your arrival to avoid problems or delays.

 

Services Required              Will you need any of the following?

 

1.  Non-Standard Electrical Power?                                                                                 Yes __ No __

 

2.  Water?                                                                                                                              Yes __ No __

 

3.  Air?                                                                                                                                   Yes __ No __

 

4.  Equipment (power supplies, etc)?                                                                               Yes __ No __

 

5.  Machine Shop Services?                                                                                               Yes __ No __

 

If you answered “yes” to any of the above questions, describe in the space below. (Attach additional sheets if necessary.)

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

 

 

Please list all attendees and their affiliations below.

 

                Attendees                                              Affiliation                                            BNL/Guest ID#

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

 

Arrival/Departure Dates ___________________    Local Accommodation Phone # _____________

 

Personnel Safety Information

 

1.     Are there participants who would require physical assistance in case of building evacuation?                   Yes __ No __

 

2.     Are there participants who would experience difficulty comprehending emergency instructions

        due to hearing or language considerations?                                                                                                           Yes __ No __

 

3.     Are there participants with medical implants that would be affected by strong magnetic fields?               Yes __ No __

 

If you answered “yes” to any of the above questions, describe in the space below. (Attach additional sheets if necessary.)

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

      _____________________________________________________________________________

 

List Ion Species Requested: __________________________________________________________

 

I understand that modification of BNL or other users' equipment is strictly prohibited without prior approval. Any modification requires approval of the Operations Supervisor and may require Tandem Safety Committee approval.


PLEASE NOTE:

 

IT IS IMPORTANT THAT ALL USERS REGISTER ON-LINE PRIOR TO ARRIVAL AT BNL.

 

This is a requirement which is now a simple procedure, with the implementation of a lab-wide user database.

 

PLEASE NOTE THAT APPROVAL OF FOREIGN NATIONAL VISITORS REQUIRES AT LEAST 20 DAYS AND POSSIBLY AS LONG AS 30 DAYS FOR VISITORS FROM SENSITIVE COUNTRIES.

 

This registration is a one-time process that will result in the issuance of a visitor's ID badge for future use.

If it is not accomplished prior to your arrival, you run the risk of not being allowed entrance to the BNL site.

 

Our users must maintain and keep current their training status.

 

Returning users, please visit the BNL Training Website to view individual history and any required updates.

New users, please visit the Users' Center Training Website to complete the following five required courses:

 

1.             Cyber Security

2.                   Computer Use Agreement

3.                   Guest Site Orientation (TQ-GSO)

4.                   General Employee Radiological Training (TQ-GERT)

5.                   Basic Electrical Safety (HP-OSH-150A)

 

You may use either your GR # (digits only) or your permanent ID number issued to you via e-mail from the RHIC/AGS Users’ Center to access these courses. Completing these requirements before your visit will enable you to make full use of your time at the TVDG.

 

We require a completed copy of this form at least 7 days prior to the start of your run. Print a copy of this form, answer all the questions and FAX it to (631) 344-4583.

 

We appreciate your cooperation. Thank you!

 

If you need assistance in completing this form, please contact us at:

(631) 344-4581                    Voice

(631) 344-4583                    Fax

ccarlson@bnl.gov     e-mail to Chuck Carlson

sandylee@bnl.gov     e-mail to Sandy Asselta

 

 

 

 

User Signature: ____________________________________________           Date: ____________

Please sign, date, and fax to (631) 344-4583 at least 1 week prior to run.

 

 

 

 

_____________________USERS, PLEASE DO NOT WRITE BELOW THIS LINE_________________________

 

Reviewed by TVDG Operations Supervisor, or Group Leader?                                  Yes __ No __

 

Is there a need for a Tandem Safety Committee Review?                                         Yes __ No __

 

 

____________________________________________                         Date _________________

Authorized Signature