ࡱ> OQNM bjbj== "DWWl : : : : 4n  ^<d$s &QTTT&twtttTtTtt   < 0 : j  0 1t1 t  SITE AND PROCESS ASSESSMENT FORM RESPIRATORY PROTECTION REQUEST Department: FORMTEXT      Building: FORMTEXT      Room Number: FORMTEXT      Supervisor: FORMTEXT      Phone: FORMTEXT      The following questions must be answered prior to submitting a request for respiratory protection:1.Is the chemical inventory list in the EOHS HazMat database for this location being updated regularly?  FORMCHECKBOX  Yes FORMCHECKBOX  No2.Is there MSDS information available for all the chemicals located in this room? FORMCHECKBOX  Yes FORMCHECKBOX  NoIf "Yes," where are the MSDS' located?3.Are the chemicals in this room properly labeled? FORMCHECKBOX  Yes FORMCHECKBOX  No4.List the hazards for which you are requesting a respirator (e.g., Formaldehyde target toxic/carcinogenic substance)Do you have the MSDS for each chemical listed? FORMCHECKBOX  Yes FORMCHECKBOX  No ChemicalClassificationEntry RoutesTarget Organs FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       5.Explain the process involving these chemicals which will require the use of a respirator: FORMTEXT      6.List the potential for exposure: FORMTEXT      7.Have you received any training in the Hazard Communication Standard: FORMCHECKBOX  Yes FORMCHECKBOX  NoIf "Yes," list date and name of trainer:Name:  FORMTEXT      Date:  FORMTEXT      8.List any other Personal Protection Equipment which you use: FORMTEXT       FORMTEXT       FORMTEXT      NAMEDATE FORMTEXT       FORMTEXT      TELEPHONEWHAT IS THE BEST TIME TO REACH YOU?  468BDF`bvxz01?@AFGUj,UjUjDU jUj>*Uj\>*Uj>*Ujt>*Uj>*UmHnHuj>*U>* j>*U 5CJ\;BDFY$$IfsFA$3 6    4 sa$If$a$ FH` $Ifl$$Ifs\Ad$3 # 64 saFGJ~X4$$Ifs4$h%64 sa$IfF$$Ifs0A$64 sa0F[$Ifl$$Ifs\!$]64 saUVW   $ & ( 2 4 6 8 L N P Z \ ^ ` t v x jUj@UjUjXUjUmHnHujU B*ph5B*CJ\phjpUjUjUjU jUjU8[\]2Z$$Ifs4F0$6    4 sa$Ifl$$Ifs\!$pq64 sa_`abcpm$$Ifs4\!$pq64 sa$If $$Ifa$$Ifm$$Ifs4\!$pq64 sa 6 ^ QDKKKK$If$$Iflh\$   (3333333333330$%64 la ( * R z lDfffflDfffflD$If$$Iflh\$ 0$%64 la     $ & * , @ B D N P R T h j l v x z |    j Ujd Uj Ujx Uj Uj Uj UjUj*UjUmHnHu jUB  D l n    fDfd$$Iflh\$ 0$%64 la$If    2 4 6 @ B D F Z \ ^ h j n p FH\^`jj5U\j5U\mHnHuj5U\5\j5U\jUj(Uj Uj< Uj UjUmHnHujP U jU8  BDFnpXiXiG$$Ifs40$e#64 saG$$Ifs4 0$e#64 sa$If jln ",.JLN ".0D׿յ׿ի׿jUjUmHnHuj\Uj>*Uj`>*Uj>*UmHnHuj>*U>* j>*UjtUjU jU5\j5U\6pv,VXZ|m$$Ifs4 \!$]64 sa$If CXG$$Ifs4 0$e#64 sa$Ifm$$Ifs4\$BB64 sa ",V0Z$$Ifs4F$k 6    4 sa$IfG$$Ifs40$e#64 sa,.VXCZ$$Ifs4F$k 6    4 sa$IfZ$$Ifs4F$k 6    4 saDFHRTVXZnpr|~jU>*jUmHnHu jUjXUZ$$Ifs4F$k 6    4 sa$If 1h/ =!"#$%tDText1tDText2tDText3tDText4tDText5tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck8tDText6tDText7tDText8tDText9vDText10vDText11vDText12vDText13vDText14vDText15vDText16vDText17vDText18vDText19vDText20vDText21vDText22vDText23vDText24vDText25vDText26vDText27tDeCheck9vDeCheck10vDText28DText29M/d/yyyyvDText30vDText31DText32M/d/yyyyvDText33vDText34 i@@@ Normal OJQJ^J_HaJmH sH tH F@F Heading 1$$@&a$5B*CJ\ph<A@< Default Paragraph Font D !"ABNbcdnFGJ0F[\]_`abc0DEYm#78L`t"#$89<  KLMabvw0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000U  jD  F[  p, ! NZ`nz0@FV(.0<BEQWYekmy !#/58DJLX^`lrt$06 MY_bntwFFFFFG G G G G G G G FFFFFFFFFFFFFFFFFFFFFFTG$G$FTFTFTFTFTFTFT,Text1Text2Text3Text4Text5Check1Check2Check3Check4Check5Check6Check7Check8Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Text19Text20Text21Text22Text23Text24Text25Text26Text27Check9Check10Text28Text29Text30Text31Text32Text33Text34Oo1G 1FZn$9Mau%Ncx  !"#$%&'()*+aAW/CXl"6K_s7 `uu{ Administrator5F:\documentation\SITE_AND_PROCESS_ASSESSMENT_FORM.doc AdministratorvC:\WTSRV\Profiles\jeanah.001\Application Data\Microsoft\Word\AutoRecovery save of SITE_AND_PROCESS_ASSESSMENT_FORM.asdBNbcdnFGJ0F[\]_`abc0DEYm#78L`t"#$89<  KLMabvw@Z_3CZZ@{L @ UnknownG: Times New Roman5Symbol3& : Arial"qha&a&a&& !dr0 2 SITE AND PROCESS ASSESSMENT FORM Administrator AdministratorOh+'0 4@ \ h t !SITE AND PROCESS ASSESSMENT FORMrosITEAdministratorSSdmidmi Normal.dotoAdministratorSS22iMicrosoft Word 9.0S@40@B龑@6ی@3*&՜.+,0  hp  University of ĢƵ, Safety  2 !SITE AND PROCESS ASSESSMENT FORM Title  !"$%&'()*+,-/0123456789:;<=?@ABCDEGHIJKLMPRoot Entry F<RData #D1Table.1WordDocument"DSummaryInformation(>8<<  FMicrosoft Word Document MSWordDocWord.Document.89q