First Name:     MI:     Last Name: Position/Task Name:     Dept/Unit/Shop: Building:    Room:    Phone:

Describe the Hazards/Agents/Products:
Are current MSDS available? Yes No
(Current MSDS are necessary for hazard assesment and respirator selection.) Describe the Activities/Processes:
Frequency of Activity/Process:
Rarely Occasionally Frequently Task Specific
Please Explain: Contaminant Forms: (Check all that apply)
Particulate Vapor Gas Current Engineering Controls: (Check all that apply)
None
Substitution by less toxic material
Isolation or enclosure of operation or process
General ventilation dilution
Local Exhaust: Hood, vented duct or other ventilation apparatus
Tools or equipment designed to minimize exposure
Other Current Administrative Controls: (Check all that apply)
Employee Training
SOP (Specify)
Other PPE/Other Equipment:(Check all that apply)

None	Gloves	Hard Hat	Face Shield	Safety Goggles
Lab Coat	Coveralls	Other

Special Uses:(Check all that apply)

None	Riot Control	Rescue	Biological Use	Chemical Spill Clean-up
Pesticide Application		Escape Only (Specify)
Confined Space Entry		Other

Physical Demands of Work:(Check all that apply)

Constant	Intermittant	Light (ie Standing)	Moderate (ie Walking)	Heavy (ie Digging)
High Temperatures		Low Temperatures	Other