Laser Information Report Form -- for Class 3b and 4 lasers.
Check the list of lasers already reported (to avoid unnecessary reporting)
To provide information or information changes, complete and return one form for each Class 3b and Class 4 laser. 

In order to determine the appropriate licensing, warning signs/devices, PPE and other controls, and training requirements for your laser system, please provide as much of the following information as possible.  *All fields are required, so that a mark of some sort is required in a field which you cannot answer.*  A REM staff member will complete the missing information and acquire much other information when the Laser Safety Survey is conducted.

*wavelength (specify units)
 		*output power
 		*class
       

*operation mode   

*type of laser

*beam diameter and divergence    

       
Brief description of the application*:
    

*Person completing form:  

*email:  
*phone:  
     
  Building & room of laser* 
Department*
Professor(s)* in charge*

*Or Center, Lab, or Facility Manager.  Must be a primary person in charge of funds.
List names of all research staff and others who have the supervisor's permission to operate of to enter this room while the laser is in operation. (Include your own name unless you will not operate laser or enter room while.....)*
    		 *laser manufacturer 
*serial number 
*Purdue ID number  

Revised: October 06, 2009.