Registration Form

Title:
Please select from this listMrMsMissMrsDrA.ProfProf

Gender:
Male  Female 

Family Name:

First Name:

Staff or Student Number:

Position:

Supervisor:

Supervisor Phone Number:

School | Centre:
Please select from this listAcquireAIBNAnimal StudiesBiomedical SciencesCMMCentre for Magnetic ResonanceCentre for Marine StudiesEngineeringLand & Food SciencesLife SciencesMolecular & Microbial SciencesPharmacyPhysical SciencesPopulation HealthSBMSSocial ScienceSustainable Minerals InstituteVeterinary ScienceOTHER

Department | Research Group:
Please select from this listAcquireAgriculture and HorticultureAnatomical SciencesAnatomy & Developmental SciencesAnimal StudiesArchaeological Science LaboratoryAustralian Materials Technology NetworkBiochemistry & Molecular BiologyBiomedical SciencesBotanyBrisbane Surface Analysis FacilityCentre for High Performance PolymerCentre for Magnetic ResonanceCentre for Marine StudiesCentre for Mining Technology and EquipmentComputer Science and Electrical EngineeringCRC for Alloy and Solidification TechnologyChemical EngineeringChemical & Structural BiologyChemistryCivil EngineeringClinical Medical Virology CentreDentistryEarth SciencesFarm Animal Medicine and ProductionGattonGlass CentreInstitute for Molecular BioscienceJKMRCLand and Food SciencesLife SciencesMechanical EngineeringMedicineMicrobiology & ParasitiologyMining, Minerals and Materials EngineeringMolecular Cell Biology & GenomicsNanomaterials CentreNanotechnology & BiomaterialsNational Research Centre for EnvironmentalNIMSPhysicsPhysiology and PharmacologyPlant ProductionPowder Metallurgy Research GroupSchool of PharmacyVeterinary ScienceVTHRCZoology and EntomologyOTHER

Faculty:
Please select from this listBiological and Chemical SciencesEngineering, Physical Sciences and ArchitectureHealth SciencesNatural Resources, Agriculture and Veterinary ScienceExternal

Workplace Address:

Mailing Address:

Telephone Number:

Email Address:

Emergency Contact Name and Address:

Relationship:

Emergency Contact Phone Number:

Relevant Medical Condition in relation to professional activities:

Have you completed a University of Queensland chool/Faculty/Unit Safety Induction?
No  Yes 

Have you completed a risk assessment for your project?
No  Yes 

List prior experience, especially courses attended at the CMM:

Will you be bringing into the CMM any chemicals/organisms/materials/samples that may be hazardous including carcinogenic, infectious or radioactive? If yes, what is the item and risk group? (Refer to MSDS forms in Hawken/Otto Laboratories).

Describe the project you will work on. What is your sample material? What are your aims and objectives? What do you require from the CMM (e.g. advice on techniques; use of equipment; training on equipment; other)?

Is training required?
No  Yes 

Type of Training required: