LABORATORY PARTICIPANT ACKNOWLEDGMENT

Laboratory Title: Introduction Start Date: 7/9/2023

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Location: 2034 Laboratory Supervisor:

Abeer Shunnar

This acknowledgement is to be completed by the participant and returned to the organizer

or designated Laboratory supervisor responsible for the supervision of the Lab activity
before the activity commences. Please note that by not completing this form or failing to
abide by the rules will be asked to leave the laboratory. Volunteers are to complete
the Volunteer Acknowledgment form.

Please tick the relevant boxes and sign the form. Yes No
I have been provided with appropriate health & safety information concerning the ~
Laboratory
I have been provided with a copy of the General Safety Conduct and am aware of ~
the foreseeable hazards associated with the Laboratory Activities
I understand my behavior on the Laboratory activity should not jeopardize the w
health & safety of others

NB: A copy of the completed form is to be kept in the unit’s office files. The original forms
are to be sent to the EHS Section to be used in the event of an audit or emergency.

In case of an emergency, the following person is to be contacted:

Name: Aisha Salem Algaydi Location:
Ras Allhaima
Contact Number: 0358129090

Name: Maitha Mussabeh Algaydi Student ID: 100062738

Signed:des Date: 719/2023

Privacy: The Khalifa University is committed to protecting your privacy. The information provided in this form
will be managed in accordance with the University’s Privacy Policy. And will only be used for the purpose of
managing your Laboratory placement(s).

MANAGEMENT SYSTEM MANUAL EHS Induction Student Acknowledgement Form

Document No: KU – FD – EHS – FOR – 107 Issue no: 01 Issue Date: 04.09.2012 Page: 1 of 1
Copies of this document available in KU EHS Intranet are only the latest, valid and controlled documents. All other copies are uncontrolled and valid only on the date printed. Last printed: 5/11/2014
12:57:00 PM