Prototyping Lab - Authorized User Request Form

Complete this form to request to become an authorized user of the QI Prototyping Facility. If approved, you will get automatic access to the Design and Assembly Space (room 1202). However, this does not give you access to use any of the machines. For all other rooms and machine access, use the separate form for Machine and Specialized Room Access.
Full Name *
Your answer
Official email address *
Your answer
Student or employee PID *
(for non-UCSD, please write "external")
Your answer
Home department *
(for non-UCSD, please write your company/school name or "personal")
Your answer
UCSD status (undergraduate/graduate/ postdoc/scientist/faculty/staff/…) *
(for non-UCSD, please write your company/school title or "individual")
Your answer
Are you on the QI payroll? *
Charge index *
(index number to charge to; if unavailable, write "unknown")
Your answer
Requested start date *
MM
/
DD
/
YYYY
Requested end date *
MM
/
DD
/
YYYY
Access Hours *
(default is Regular Business Hours; check Definitions tab for more info)
Briefly describe why you are requesting to become a user *
(include an explanation of the access hours requested if they are not Regular Business Hours)
Your answer
Additional signed forms
As part of your application to become an authorized user of the QI Prototyping Facility, you also need to complete and sign some additional forms. These need to be scanned and email to us (for our contact information: prototyping.ucsd.edu/contact.php)

* USER AGREEMENT:
http://prototyping.ucsd.edu/docs/user_agreement.pdf
* WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT:
http://prototyping.ucsd.edu/docs/waiver_of_liability.pdf
* Certificate showing successful completion of UCSD Injury and Illness Prevention Program:
http://blink.ucsd.edu/safety/occupational/hazard/IIPP/training.html
* AFTER HOUR WAIVER FOR UNDERGRADUATE STUDENTS
(only required for undergrads requesting 24/7 or Extended Business Hours access):
http://prototyping.ucsd.edu/docs/after_hour_waiver.pdf


By submitting this form, you agree to that you will comply with the Prototyping Lab User Agreement, including the Policies and Procedures and the general and machine specific safety guidelines. However, submission of this form by does not grant you the right to access the facilities or use the machines. You are not allowed to use any Prototyping Lab facilities before having received explicit approval from us.

Submit
Never submit passwords through Google Forms.
This form was created inside of UCSD Jacobs School of Engineering. Report Abuse - Terms of Service