Hazardous Substances pre-Assessment Form

 

Department:____________________________

Comments

Dept. code: _____________

(Do not Write in Margin)

Building:______________________________

Title of Department Head: ______________________

Job Title of Employee(s) Undertaking Operation or Process:

___________________________________________

EXACT Location: ____________________________

Description of Operation/Process:

Approx No. Operators Undertaking Operation/Process:

Brief Principles of Operation/Process:

Approx Frequency of Operation/Process:

Constant Very Frequent Frequent

Rare Very Rare

PTO


 

Form 1 continued

Materials/Substances Used:

Codes

(Include Supplier References and

Trade Names where applicable)

Is any Local Exhaust

Ventilation (LEV) used? YES

NO

If YES, what sort is it?

Name of Compiler: _____________________

Date: _________

 

 

 

 

Further Action:

Taken By:

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