UCLA Be Smart About Safety FUNDING APPLICATION FORM 2008-2009 INSTRUCTIONS:
APPROVAL prior to ordering equipment is requested. If REIMBURSEMENT of equipment is requested, supporting documentation must include paid invoices and copies of the general ledger sheet on which the expenses fall. 2.Reimbursement of approved funds will be completed by the requesting department using a NONPERS transfer of expense to the Equipment Improvement Program. When all required documentation is received by IRM, the department will be given necessary information to complete the transfer. 3.Requests for funds must be between a minimum $1000 to a maximum of $40,000. Funding is available for requests between July 1, 2008 and June 30, 2009 until available funds are depleted. 4.Funding requests will be reviewed and processed by the UCLA Injury Prevention Committee in the order in which they are received. Click on the "Submit" button below or click on "Print" and submit application form and required documentation to: Linda Ozamoto , EH&S, 501 Westwood Plaza, 4th Floor, Mail code 160508.
1.Complete the application form and add all requested supporting documentation. Supportive documentation should include equipment quotes if PRE-
Department Department Manager Contact Name
Proposal Submitted by
Address E-mail E-mail E-mail Type of funding request: Cost sharing IRM Purchase Amount of request Tel Tel Tel
Type of funding request: Purchase of equipment/materials Injury Prevention Project
Description of Injury Prevention Project/Equipment: (Attach additional sheets if necessary)
Justification for funding request: Include metrics related to current injury/risk rates as well as projected reduction in injury risks and workers compensation costs. Attach EH&S/IRM assessment.
I have read, understand, and accept the terms, conditions and requirements of the UCLA Be Smart About Safety fund.
Manager or Signature Authority
IPC Action Summary:
Approved Amount:
Chair/Vice Chair
Conditional Approval
Date
Not approved
Print Form
Submit by Email