Environmental Engineering Reference
In-Depth Information
tABle 22.1
health hazard evaluation Form
U.S..DEPARTMENT.OF.HEALTH.AND.HUMAN.SERVICES.
Form.Approved
U.S..Public.Health.Service.
OMB.No..0920-0260
Centers.for.Disease.Control.and.Prevention.
Expires.January.31,.2012
National.Institute.for.Occupational.Safety.and.Health
Request for Health Hazard Evaluation (HHE) .
.
(also.available.at:.www.cdc.gov/niosh/hheform.html)
Establishment Where Possible Hazard Exists
. 1.. Company.Name:.. __________________________________________________________________
. 2.. Address:.._________________________________________________________________________
. . City:..______________________________ .State:.________________ .Zip.Code:..______________
. 3.. What.product.or.service.is.provided.at.this.workplace?..____________________________________
. 4.. Specify.the.particular.work.area,.such.as.building.or.department,.where.the.possible.hazard.exists:
. . . ________________________________________________________________________________
. 5.. How.many.employees.are.exposed?..__________
. 6.. Duration.of.exposure.(hrs/day)?.. _____________
. 7.. What.are.the.occupations.of.the.exposed.employees;.what.is.the.process/task?
. . Occupations:.. _____________________________________________________________________
. . Process/task:.. _____________________________________________________________________
. 8.. To.your.knowledge,.has.NIOSH,.OSHA,.MSHA,.or.any.other.government.agency.previously.
evaluated.this.workplace?. .YES. .NO
. 9.. Is.a.similar.request.currently.being.iled.with,.or.is.the.problem.under.investigation.by,.any.other.
local,.state,.or.federal.agency?. .YES. .NO
.10.. If.either.question.8.or.9.is.answered.yes,.give.the.name.and.location.of.each.agency..._____________
. . . ________________________________________________________________________________
. . . ________________________________________________________________________________
.11.. Which.company.oficial.is.responsible.for.employee.health.and.safety?
. . Name:.. ________________________ .Title:..___________________ .Phone:.. _________________
.12.. How.did.you.learn.about.the.NIOSH.HHE.program?. .Company.representative.
.Co-worker
.Union.
.Other.employee.representative.
.NIOSH.Website.
.CDC.800.Number.(CDC-INFO)
.News.media.(TV,.radio,.newspaper,.magazine).
.Other.(please.list)..______________________
Description of the Possible Hazard or Problem
.13.. Please.list.all.substances,.agents,.or.work.conditions.that.you.believe.may.contribute.to.the.possible.
health.hazard..(Include.chemical.names,.trade.names,.manufacturer,.or.other.identifying.
information,.as.appropriate.).._________________________________________________________
. . . ________________________________________________________________________________
.14.. In.what.physical.form(s).do(es).the.substance.exist?. .Dust.
.Gas.
.Liquid.
.Mist.
.Other
.15.. How.are.the.affected.employees.exposed?.(route.of.exposure).
.Breathing.
.Skin.contact
.Swallowing.
.Other.(please.list).. _________________________________________________
[Send completed form to address listed on the reverse side]
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