Key/Proxy Authorization Form

Name *

First Last

Email *

ID# *

Current Boise State Affiliation *

Start Date *

End Date

Hidden

Are you ONLY requesting a physical key to a graduate student office at this time?

No
Yes

Hidden

If Yes, Please list the graduate student office you'll be occupying. If you are unsure, please contact Stacey Smith (MS/MA students) or Adil Refaey (EEB students).

Please select your affiliated dept/research group, or select "Not Affiliated to Any Groups Listed Here".

Other Proxy Room Access Needed:

Note: some of these spaces may already be included with one of the lab affiliations above.

Select All
Science Bldg
Science 107
Science 244 (Autoclave)
Science 249 (Shared Equipment Room)
Science 401 (Biohazard Disposal)

Please list the equipment to be used in SC249. *

Additional Proxy Access:

Additional Physical Key Access:

Hidden

Are any of the rooms listed above labs? *

Yes
No

Reason for Access/Description of Work: *

Emergency Contact Number: *

Please enter the best contact number to notify you of emergencies and evacuation notices

Training and Certification Required

Lab Worker Safety Checklist *

Please attach the email (or screenshot showing your name and date of completion) you received upon completing the Lab Worker Safety Checklist.

Drop files here or

Max. file size: 10 MB.

EHSS Training *

Per Shay Gillette, "All lab workers should complete BSU EHSS online lab safety training at https://cems.unh.edu/boisestate Log in to the system by clicking on login and then clicking on the TOP Boise State University User Login (don't immediately enter your information under "other users.") Then enter your BSU credentials. From there, on your homepage / dashboard, click on the training link near the bottom. Then click on "view available courses." Please complete the following three courses: A Day in the Lab, Hazardous Waste Training, and Lab Safety. UNH CEMS only works through Boise State's IP address. So, you will either need to complete the training while on campus or use Boise State's Virtual Private Network (VPN). This allows you to use their IP address while off campus. To use the VPN, please follow the directions after clicking on the link." Please attach the certificate of completion (or screenshot showing your name and date of completion) you received upon completing the EHSS Training.

Max. file size: 10 MB.

CITI Training

If Applicable, Please attach the Certificate of Completion (or screenshot showing your name and date of completion) you received upon completing the CITI Training. CITI Program training is for anyone working with potentially biohazardous materials. If you are a TA teaching an A&P class, Microbiology or Human/Comparative Phys. (or any other lab using potentially infectious materials) you will need to register for an account (https://www.citiprogram.org/index.cfm?pageID=154&icat=0&clear=1) and complete the Biosafety Essentials module (this is also valid for one year). If you work with human tissues or potentially infectious material in your research you may need to do additional modules and print a completion certificate for your lab's safety training binder.)

Max. file size: 10 MB.

Enter Reviewer Email

Please list the email address of the supervisor(s), advisor(s), or researcher(s) granting you access to the room(s). Additional lines are provided below if needed, but at least one individual must be listed to approve your request.

Email *

Email

Key/Proxy Authorization Form

Training and Certification Required

Enter Reviewer Email

Department of Biological Sciences