HomeMy WebLinkAboutAPP FORMSTraining Documentation Form
Accident Prevention Program, safety orientation
Personal Protective Equipment Type:
Chemical Hazard Communication
First Aid Orientation
Portable Fire Extinguishers
Other:
Date(s) of training:
Description of
Training:
List of employee(s) who completed this training:
Trainer: ____________________________________
Job Hazard Analysis
1. Analysis information
Work
activity Enter text. JHA
no. 1 New or
revised
Enter
text.
Date Enter a
date.
Department Enter text. Staff
name Enter text. Position Enter text.
Reviewing
Staff Enter text. Approval (reviewer signature) Date Enter a
date.
2. Work activity review
Work activity tasks Identified hazards Controls for identified
hazards
1. Click here to enter text. 2. Click here to enter text. 1. Click here to enter text.
3. Equipment and training determinations
Required personal protective equipment (PPE) [Briefly note the hazard the selected
PPE is addressing]
1. Click here to enter text.
Required or recommended training needed prior to undertaking work activity
Click here to enter text.
Comments or rationale for findings (if needed)
Click here to enter text.
First Aid Log Location: ______________________________________________
Employee Name Job Title Date Time Nature of Injury
Treatment
Received
Employee’s Report of Incident Form
Please Submit to Human Resources within 24 Hours of Incident
Instructions: Employees shall use this form to report all work related injuries, illnesses, or “near
miss” events (which could have caused an injury or illness) – no matter how minor. This helps us to
identify and correct hazards before they cause serious injuries. This form shall be completed by
employees as soon as possible and given to a supervisor for further action.
I am reporting a work related: D Injury D Illness D Near miss
Your Name:
Job title:
Supervisor:
When did you tell your supervisor about this injury/near miss?
Date of injury/near miss: Time of injury/near miss:
Names of witnesses (if any):
Where, exactly, did it happen?
What were you doing at the time?
Describe step by step what led up to the injury/near miss. (continue on the back if necessary):
What could have been done to prevent this injury/near miss?
What parts of your body were injured? If a near miss, how could you have been hurt?
Do you plan or did you see a doctor about this injury/illness? D Yes D No
If yes, whom did you see? Doctor’s phone number:
Date: Time:
Has this part of your body been injured before? D Yes D No
If yes, when?
Your signature: Date:
Supervisor’s Incident Investigation Report
Please return to Human Resources within three business days of incident.
Instructions: Complete this form as soon as possible after an incident.
This is a report of a: ❑ Death ❑ Injury ❑ Lost Time ❑ Dr. Visit ❑ First Aid ❑ Near Miss (check all that apply)
Date of incident: This report is made by: ❑ Supervisor ❑ Team ❑ Other
Step 1: Injured employee (complete this part for each injured employee)
Name: Sex: ❑ Male ❑ Female Age:
Department: Job title at time of accident:
Part of body affected: (shade all that apply)
Nature of injury: (most
serious one)
❑ Abrasion, scrapes
❑ Amputation
❑ Broken bone
❑ Bruise
❑ Burn (heat)
❑ Burn (chemical)
❑ Concussion (to the head)
❑ Crushing Injury
❑ Cut, laceration, puncture
❑ Hernia
❑ Illness
❑ Sprain, strain
❑ Damage to a body system:
❑ Other ___________
This employee works:
❑ Regular full time
❑ Regular part time
❑ Seasonal
❑ Temporary
Months with
this employer
Months doing
this job:
Step 2: Describe the incident
Exact location of the incident: Exact time:
What part of employee’s workday? ❑ Entering or leaving work ❑ Doing normal work activities
❑ During meal period ❑ During break ❑ Working overtime ❑ Other ____________
Names of witnesses (if any):
Number of
attachments:
Written witness statements: Photographs: Maps / drawings:
What personal protective equipment was being used (if any)?
Describe step by step the events that led up to the injury. Include names of any machines, parts, objects,
tools, materials and other important details.
Description continued on attached sheets: ❑
Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)
❑ Inadequate guard
❑ Unguarded hazard
❑ Safety device is defective
❑ Tool or equipment defective
❑ Workstation layout is hazardous
❑ Unsafe lighting
❑ Unsafe ventilation
❑ Lack of needed personal protective equipment
❑ Lack of appropriate equipment / tools
❑ Unsafe clothing
❑ No training or insufficient training
❑ Other: _____________________________
Unsafe acts by people: (Check all that apply)
❑ Operating without permission
❑ Operating at unsafe speed
❑ Servicing equipment that has power to it.
❑ Making a safety device inoperative
❑ Using defective equipment
❑ Using equipment in an unapproved way
❑ Unsafe lifting by hand
❑ Taking an unsafe position or posture
❑ Distraction, teasing, horseplay
❑ Failure to wear personal protective equipment
❑ Failure to use the available equipment / tools
❑ Other: __________________________________
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”)
that may have encouraged the unsafe conditions or acts? ❑ Yes ❑ No
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident? ❑ Yes ❑ No
Have there been similar accidents or near misses prior to this one? ❑ Yes ❑ No
Step 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening again?
❑ Stop this activity ❑ Guard the hazard ❑ Train the employee(s) ❑ Train the supervisor(s)
❑ Redesign task steps ❑ Redesign work station ❑ Write a new policy/rule ❑ Enforce existing policy
❑ Routinely inspect for the hazard ❑ Personal Protective Equipment ❑ Other: ____________________
What should be (or has been) done to carry out the suggestion(s) checked above?
Description continued on attached sheets: ❑
Step 5: Who completed and reviewed this form? (Please Print)
Written by:
Department:
Title:
Date:
Names of investigation team members:
Reviewed by:
Title:
Date:
ACCIDENT INVESTIGATION WITNESS STATEMENT FORM
Company Name: Date of Accident:
Injured Party: Time of Accident:
Project Name:
Witness Name: Witness Phone #:
Witness Address:
WITNESS STATEMENT
INSTRUCTIONS: Complete in your own words, the immediate events leading up to and including
the accident. Your effort to provide complete descriptive details of the events is essential to
determine the facts about this accident.
I have read the above statement and certify that it is true to the best of my knowledge.
Witness Signature: Date:
Supervisor Signature: Date:
VEHICLE ACCIDENT REPORT FORM
Form must be submitted within 5 days of accident/incident
Employee Name
Was a Police Report Filed?
Yes ☐ No ☐
Project Location
Police Report # ___________
Location of accident/incident
Accident/incident occurred
Date Time
Did this accident result in an injury?
Yes ☐ No ☐ If yes, please complete injury details
Accident/incident reported
Date Time
Name of any witnesses
Accident/incident resulted in (mark all that apply)
Fatality First aid only Medical treatment
required
Workdays
lost Equipment damage
Describe injuries
Describe how accident/incident occurred
What actions, events, or conditions contributed most directly to this accident/incident?
What could be done to prevent future accidents/incidents of this type?
Both Parties must sign below
Date
Printed name of employee
Signature
Date
Printed Name of supervisor
Signature
GENERAL HAZARDOUS CHEMICAL LIST
Product Name Chemical Name Amount Location SDS on
File
Unleaded Gasoline Gasoline, All Grades Gallons Vehicle Yes
Diesel Fuel Diesel Fuel No. 2 Gallons Vehicle Yes
Anti-Freeze Ethylene-Glycol
Gallons Vehicle Yes
Engine Oil 15W40 Engine Oil (& the like
consistencies)
Quarts Vehicle Yes
Window Washer Fluid Window Washer Fluid ~1 Gallon Vehicle Yes
Automatic Transmission
Fluid
Automatic Transmission Fluid < 1 qt. Vehicle Yes
Brake Fluid DOT 4 Brake Fluid < 1 qt. Vehicle Yes
Hydraulic Fluid Hydraulic Fluid Varies Various Jobsite
Equipment Yes
Additional Hazardous Chemicals shall be added to this log on a project-specific basis. This should be updated to reflect any
changes based upon project-specific chemical exposure
1. TYPICAL HAZARDOUS CHEMICAL IN CONSTRUCTION
Substance Known or Suspected
Health or Physical Hazards Where Found
Acetylene Flammable; combustible Welding/burning operations
Arsenic Lung and skin cancer Wood preservatives
Asbestos Lung cancer Water Mains, Insulation, building
products, water mains
Benzene Leukemia Solvents, glues
Calcium Oxide
(Lime) Skin, eye and respiratory irritant Concrete and masonry
Coal Tar/Asphalt Eye and respiratory irritant Roof and foundation work
Concrete/Mortar Irritant Concrete and masonry
Curing Compound Flammable; combustible, irritant Concrete
Epoxy Resin
Severe irritant to skin, eyes and
respiratory tract; some suspected of
causing cancer, some flammable
Adhesives
Form Oil Irritant Concrete work
Formaldehyde Nasal and brain cancer Plywood, particle board, foam
insulation
Fuels and
Lubricants Flammable; combustible, irritant Internal combustion engines; heaters
Glass Fiber Dust Irritant Insulation
Lead Kidney, blood and nervous system; skin and
eye irritation Plumbing and roofing work; soldering
Methylene Chloride Cancer, heart, liver, nervous system, skin
and eye irritation
Paint stripping solvents, cleaning
solvents, polyurethane foam
Muriatic Acid Severe irritant especially to eyes and
mucus membranes Masonry work
Oxygen Supports combustion in flammable and
combustible areas Welding/burning operations
Quartz Dust (Silica) Lung scarring Limestone and granite aggregates
Trichloroethylene Lung cancer, central nervous system
depressant solvents, paint, resin, varnish
Vinyl Chloride Liver cancer Polyvinyl chloride plastics
Welding Fumes
from Nickel,
Beryllium and
Chromates
Lung and nasal cancer Welding
Wood Dust Irritant; nasal, colon and rectal cancer Woodworking
Xylene Flammable; combustible, irritant Concrete
HAZARDOUS CHEMICAL LABELING SYSTEM
a) Globally Harmonized System (GHS) b) HMIS Labeling
c) NFPA 704 Diamond
a. Globally Harmonized Systems:
GHS Elements:
Description Pictogram Hazard class and hazard category:
Exploding
Bomb
Unstable explosives
Explosives of Divisions 1.1, 1.2, 1.3, 1.4
Self-reactive substances and mixtures, Types A,B
Organic peroxides, Types A,B
Flame
Flammable gasses, category 1
Flammable aerosols, categories 1,2
Flammable liquids, categories 1,2,3
Flammable solids, categories 1,2
Self-reactive substances and mixtures, Types
B,C,D,E,F
Pyrophoric liquids, category 1
Pyrophoric solids, category 1
Self-heating substances and mixtures, categories
1,2
Substances and mixtures, which in contact with
water,
Emit flammable gases, categories 1,2,3
Organic peroxides, Types B,C,D,E,F
Flame Over
Circle
Oxidizing gases, category 1
Oxidizing liquids, categories 1,2,3
Gas Cylinder
Gases under pressure:
- Compressed gases
- Liquefied gases
- Refrigerated liquefied gases
- Dissolved gases
Corrosion
Corrosive to metals, category 1
Skin corrosion, categories 1A,1B,1C
Serious eye damage, category 1
Skull and
Crossbones
Acute toxicity (oral, dermal, inhalation),
categories 1,2,3
Exclamation
Mark
Acute toxicity (oral, dermal, inhalation), category
4
Skin irritation, category 2
Eye irritation, category 2
Skin sensitization, category 1
Specific Target Organ Toxicity – Single exposure,
category 3
Health Hazard
Respiratory sensitization, category 1
Germ cell mutagenicity, categories 1A,1B,2
Carcinogenicity, categories 1A,1B,2
Reproductive toxicity, categories 1A,1B,2
Specific Target Organ Toxicity – Single exposure,
categories 1,2
Specific Target Organ Toxicity – Repeated
exposure, categories 1,2
Aspiration Hazard, category 1
Environment
Hazardous to the aquatic environment
- Acute hazard, category1
- Chronic hazard, categories 1,2
a. HMIS Labeling
General Rating Summary:
Health Rating Chart
* Chronic Hazard Chronic (long-term) health effects may result from
repeated exposure.
0- Minimal Hazard No significant risk to health.
1- Slight Hazard Irritation or minor reversible injury possible.
2- Moderate Hazard Temporary or minor injury may occur.
3- Serious Hazard Major injury likely unless prompt action is taken and
medical treatment is given.
4- Severe Hazard Life-threatening, major or permanent damage may
result from single or repeated exposures.
Flammability Rating Chart
0- Minimal Hazard Materials that will not burn.
1- Slight Hazard
Materials that must be preheated before ignition will
occur. Includes liquids, solids, and semi-solids having a
flash point above 200° F. (Class IIIB)
2- Moderate Hazard
Materials which must be moderately heated or exposed
to high ambient temperatures before ignition will occur.
Includes liquids having a flash point at or above 100°F,
but below 200°F. (Class II & IIIA)
3- Serious Hazard
Chemicals capable of ignition under almost all normal
temperature conditions. Includes flammable liquids
with a flash point between 73°F and 100°F. (Class IB &
IC)
4- Severe Hazard
Flammable gasses or very volatile flammable liquids
with flash points below 73°F and boiling points below
100°F. Materials may ignite spontaneously with air.
(Class IA)
Reactivity Rating Chart
0- Minimal Hazard
Materials that are normally stable, under fire conditions
and will not react to water, polymerize, decompose,
condense or self-react.
1- Slight Hazard
Materials that are normally stable, but can become
unstable at high temperatures and pressures. Materials
may react non-violently with water or undergo
hazardous polymerization in the absence of inhibitors.
2- Moderate Hazard
Materials that are unstable and may undergo violent
chemical change at normal temperature and pressure
with low risk for explosion. Materials may react
violently with water or form peroxides upon exposure
to air.
3- Serious Hazard
Materials that may form explosive mixtures with water
and are capable of detonation or explosive reaction in
the presence of a strong igniting source or undergo
chemical change at normal temperature and pressure
with moderate risk of explosion.
4- Severe Hazard
Materials that are readily capable of water reaction,
detonation or explosive decomposition at normal
temperatures and pressures.
General Rating Summary:
Health (Blue)
Rating Kind of
Hazard Description
4 Danger May be fatal on short exposure. Specialized protective
equipment required
3 Warning Corrosive or toxic. Avoid skin contact or inhalation
2 Warning May be harmful if inhaled or absorbed
1 Caution May be irritating
0 No unusual hazard
Flammability (Red)
Rating Kind of
Hazard Description
4 Danger Flammable gas or extremely flammable liquid
3 Warning Flammable liquid flash point below 100° F
2 Caution Combustible liquid flash point of 100° to 200° F
1 Combustible if heated
0 Not combustible
Reactivity (Yellow)
Rating Kind of
Hazard Description
3 Danger May be explosive if shocked, heated under confinement or
mixed with water
2 Warning Unstable or may react violently if mixed with water
1 Caution May react if heated or mixed with water but not violently
0 Stable
Not reactive when mixed with water
Special Notice Key (White)
W Water Reactive
OX Oxidizing Agent
PPE Assessment Form
Hazard Frequency Occurs PPE Required
Access & Egress
Chemical/Biological
Compression/Crushing
Confined Space Hazards
Drowning
Electrical
Engulfment
Ergonomic
Drowning
Fire Potential
Harmful Dust
Hot/Cold Equipment
Impact
Light (Optical) Radiation
Material Handling
Material Storage
Noise
Penetration
Radiation (Ionizing)
Tools
Vibration
Walking Surfaces
Weather
Injury/Accident Data
FIRST AID KIT INSPECTION LOG
Department/Location: ______________________
Month Year Inspector’s Signature Comments
Monthly/quarterly inspection includes:
- Verify first aid kit is in assigned location.
- Ensure there are no items beyond the expiration date.
- Restock any items that have been used or damaged.
- Retain completed form to show upon safety committee inspections.
FIRST AID KIT INSPECTION LOG
Department/Location:______________________________
Location Location Location
Date Signature Date Signature Date Signature
Location Location Location
Date Signature Date Signature Date Signature
Monthly/quarterly inspection includes:
- Verify first aid kit is in assigned location.
- Ensure there are no items beyond the expiration date.
- Restock any items that have been used or damaged.
- Retain completed form to show upon safety committee inspections.
Performed By: __________________ Date of Assessment: __________________
OSHA STANDARDS REQUIRING FIRE EXTINGUISHERS IN CONSTRUCTION
STANDARD LOCATION TYPE DISTANCE
150 (c) (1) (i) Building area 2A 100 feet
150 (c) (1) (iv) Each floor 2A -------
150 (c) (1) (iv) Multistory building 2A Adjacent to stairway
150 (c) (1) (vi) 5 gal. of flammable/
combustible or 5 lb.
of flammable gas
10B 50 feet
151 (c) (6) Open yard storage 2A or suitable for
Hazard
100 feet
152 (d) (1) Flammable liquid
storage room
20B 10 feet, outside
152 (d) (2) Outside flammable
liquid storage area
20B 25 to 75 feet
152 (d) (4) Vehicles used for
dispensing or trans-
porting flammable or
combustible liquids
20B:C On vehicle
152 (g) (11) Service or fuel area 20B:C 75 feet
153 (l) LPG storage area 20B:C -------
352 (d) Welding, cutting, or
heating areas
Suitable -------
550 (a) (14) (i) Crane cabs 5B:C On crane
800 (m) (8) Tunnel machinery
not
using fire-resistant
hydraulic fluid
4A:40B:C -------
800 (m) (11) Tunnel underground
belt conveyors at
head & tail pulley
4A:40B:C -------
902 (i) Vehicles used for
trans-
portation of
explosives
10A:B:C -------
CONVERSION OF FIRE EXTINGUISHER CLASSIFICATIONS
Type 2 A = 2½ gallon water pump or Type 20 B:C = 30 pounds of
pressure extinguisher dry chemical
Type 10 B = 17 gallon foam extinguisher Type 5 B:C = 20 pounds of
carbon dioxide
Type 20 B = 33 gallon foam extinguisher Type 4 A:40 B:C = 17 gallons water &
75 to 350 pounds of dry chemical
Note: For multi-use purposes, it is recommended that 5 to 20 A:B:C fire extinguishers be used
on all agency projects.
FIRE EXTINGUISHER INSPECTION LOG
Month/ Year: Date:
Location
Number
Type
Appearance Hose Guages Inspection
Plate
Pin
Retainer
Comments:
Inspected By:
Using a Fire Extinguisher – Training Supplement
The following steps should be followed when
responding to incipient stage fire:
▪ Alert others and call the fire department.
▪ Identify a safe evacuation path before approaching the fire. Do not allow the
fire, heat, or smoke to come between you and your evacuation path.
▪ Select the appropriate type of fire extinguisher.
▪ Discharge the extinguisher within its effective range using the P.A.S.S.
technique (pull, aim, squeeze, sweep).
▪ Back away from an extinguished fire in case it flames up again.
▪ Evacuate immediately if the extinguisher is empty and the fire is not out.
▪ Evacuate immediately if the fire progresses beyond the incipient stage (small fire).
Most fire extinguishers operate using the following P.A.S.S. technique:
1
.
PULL... Pull the pin. This will also break the tamper
seal.
2
.
AIM... Aim low, pointing the extinguisher nozzle (or its horn
or hose) at the base of the fire.
Note: Do not touch the plastic discharge horn on CO2
extinguishers, it gets very cold and may damage skin.
3
.
SQUEEZE... Squeeze the handle to release the
extinguishing agent.
4
.
SWEEP... Sweep from side to side at the base of the fire
until it appears to be out. Watch the area. If the fire re -
ignites, repeat steps 2 - 4.
If you have the slightest doubt about your ability
to fight a fire....EVACUATE IMMEDIATELY!
HOT WORK PERMIT
Time Hot Work Allowed ___________ To ___________ Date
Job Description
Type Of Work Melting Pot
Electric Welding Chiseling
Red Heading Grinding
Powder Gun Brazing
Hammering Soldering
Gas Welding/Burning Drilling
Other
Alarms Must Be Cut Off Yes Yes
Fire Watch Required Yes No
Vapor/Gas Combustion
Test Required Yes No
Special Instructions
Approvals (Signatures)
Shift Supervisor Foreman
Day
Swing
Night
Person Doing The Work Must Check
Items and Sign Below
Hand Fire Extinguisher In Area
Yes
Combustible Materials Removed From Area
Yes
Combustible Materials Removed From Area Below
Yes
All Flammable Liquids Removed From Area
Yes
All Flammable Gas Shut-Off And Isolated
Yes
Welding Screens Positioned Where Needed
Yes
Sheathing Provided Where Needed
Yes
Welding Cables And Hoses Out Of Travel
Areas Or Secured At Least 7' Overhead
Yes
Vapor Combustion Test Conducted
Yes
Vapor Combustion Test Conducted
Where Necessary
Yes
If Tested, Who Conducted Test?
Test Results
Using Pipe as Required on Special Work Permit
Yes
Signature of Person Performing The Hot Work
Ladder Inspection Log
Project Name: Employer Name: Inspected By: Date: Color Code:
I.D. NUMBER STEP
LADDER
SINGLE
LADDER
EXTENSION
LADDER
JOB MADE
LADDER
OTHER
TYPE____________
COMMENTS
OK NO OK NO OK NO OK NO OK NO
INSTRUCTIONS : All ladders shall be inspected monthly by a competent person. Those that are discovered to have a defect shall be tagged
"UNSAFE DO NOT USE" and removed from the work area for repair or destruction. Inspect for defects including broken or
missing rungs, broken or split siderails, or other faulty or defective construction. Those that are in good condition shall be color
coded with the safety color code of the month. Color code tape shall be placed (one wrap) on the right side rail between the third
and fourth rungs or steps. The effective date for color codes shall be the first work day of each month. Complete this inspection
form by placing a check under “OK” if the ladder meets requirements of the regulation or a check under “NO” if the ladder is
defective and removed from service. Ladders must have an I.D. number.
Fall Protection Inspection Log
Project Name Employer Name Date
Inspected By Color Code
Instructions:
1. All parts of safety harness and attachments are to be checked for excessive wear and damage
2. A √ symbol indicates Yes or OK
An X symbol indicates No or Replace
3. To be inspected monthly and report turned in at Safety Department
Employee
Name /
Location
Badge
Number
Mfg’s
Serial #
Harness
Webbing
or Leather
All
Stitching
Rivets
and
Eyelets
D Ring(s)
Buckle(s)
include
Tongue
Body Pad
(if
applicable)
Lanyard Hook
Safety
Latch
Certification
or Data Tag
FALL PROTECTION WORK PLAN
Instructions: A competent person qualified to recognize fall hazards and who knows the fall
protection rules must write a plan for this worksite if a fall hazard(s) of 10 feet or more will exist
while employees are on site. Fill in the blanks and check the appropriate boxes. A copy of
this plan must be on the worksite while employees are on site.
B. Worksite information
Company Name: Date Prepared: / /
Worksite Address: City:
Competent Person to Supervise the Plan:
Where will this plan will be posted?
Check all that apply
❑ Standard Guardrails: Are to be made from 2 X 4’s with posts spaced
no more than 8’ apart. The top rail must be 39" to 45" above the work
surface with a midrail at the half-way point and a toe board if workers will
walk or work below. The rail must withstand 200 pounds of pressure on
the top rail in any direction. Note: A guardrail does not protect a person
standing on a ladder, stilts, a box or other surface above the work surface.
Additional Instructions:
❑ Roof > 4/12 Pitch
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Window Opening
❑ Open Sided Floor
❑ Deck / balcony
❑ Leading Edge
❑ Scaffold Work
❑ Mobile Lift Work
❑ Ladder Work
❑ Excavation Edge
❑ Grade Drop-Off
❑ Other:
❑ Fall Arrest Harness: Anchor points must be capable of withstanding
5000 pound shock unless a deceleration device in use limits free fall to 2
feet in which case a 3000 pound anchor point may be used.
Anchors points are:
Configuration and placement sketch attached: ❑ Yes ❑ No
Manufacturer’s installation instructions attached? ❑ Yes ❑ No
Free fall may not exceed 6'. A lower level may not be contacted during a
fall. Lifelines must be placed or protected to prevent abrasion damage.
Snap hooks may not be connected to each other, or to loops in webbing.
Harness manufacturer:
Manufacturer’s use and care instructions attached? ❑ Yes ❑ No
Additional Instructions:
❑ Roof > 4/12 Pitch
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Open Beam
❑ Truss/Top Plate
❑ Window Opening
❑ Open Sided Floor
❑ Deck / Balcony
❑ Leading Edge
❑ Scaffold Work
❑ Mobile Lift Work
❑ Ladder Work
❑ Excavation Edge
❑ Grade Drop-Off
❑ Other:
Fall protection methods Identified Fall hazards above 10 feet
Check all that apply
❑ Fall Restraint Harness: Anchor points must be able to withstand 4
times the body weight with tools of the heaviest person who will use the
system. The system must always be rigged to prevent a free fall from the
work surface. Several alternate anchor points may be necessary to
prevent free fall from any location. If a horizontal catenary line is used, it
will be designed by a competent person who recognizes that a horizontal
line can multiply the force applied to the anchor.
Anchors points are:
Configuration and placement sketch attached: ❑ Yes ❑ No
Manufacturer’s installation instructions attached? ❑ Yes ❑ No
Harness manufacturer:
Manufacturer’s use and care instructions attached? ❑ Yes ❑ No
Additional Instructions:
❑ Roof > 4/12 Pitch
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Window Opening
❑ Open Sided Floor
❑ Deck / Balcony
❑ Leading Edge
❑ Scaffold Work
❑ Mobile Lift Work
❑ Excavation Edge
❑ Grade Drop-Off
❑ Other:
❑ Warning Line System: A line made up of ❑ rope ❑ wire or ❑ chain
between 36" - 42" above the surface flagged at 6 foot intervals will be
attached to stanchions such that pulling on one section of chain will not
take up slack in the other sections. The stanchions must be able to
withstand a 16 pound force applied horizontally at 30" high. The warning
line will be erected at least 6 feet back from the fall hazard. It will be set
up so that a person entering will be directed to the work zone and
prevented from entering unprotected areas.
Configuration and placement sketch attached: ❑ Yes ❑ No
Additional Instructions:
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Window Opening
❑ Open Sided Floor
❑ Deck / Balcony
❑ Leading Edge
❑ Other:
❑ Safety Monitor System: A warning line will be erected a minimum of
6' back from the roof or leading edge. Authorized employees working in
the zone between the fall hazard and the warning line will be monitored by
a competent person designated as safety monitor. The monitor and the
employees (maximum 8) will wear high visibility vests. The monitor’s vest
will be marked “Monitor". The monitor will be in visual and voice range of
employees in the control zone and have no other duties except watching,
warning and directing employees regarding fall hazards. This system will
not be used in adverse weather conditions such as snow, rain, or high
wind or after dark.
Monitor(s):
Control Zone Employees:
Additional Instructions:
❑ Leading Edge
❑ Roof =< 4/12
Pitch
All other uses
prohibited per
WAC 296-155-
24521(1)
Fall protection methods Identified Fall hazards above 10 feet
Check all that apply
❑ Hole/opening cover: It must be able to support 2 X the weight of
employees and equipment. It will be secured to prevent accidental
displacement. We will use ❑ hinges ❑ cleats nailed to the underside of
the cover ❑ Nail or screw it in place. It will be marked "Cover" on top.
Our covers will be made from:
Additional Instructions:
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Other:
❑ Catch Platform: Must be installed within 10' vertical of the work area.
Must be as wide as the fall distance (minimum 45”). Must have guardrails
on all open sides.
Additional Instructions:
❑ Roof > 4/12 Pitch
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Open Beam
❑ Truss/Top Plate
❑ Window Opening
❑ Open Sided Floor
❑ Deck / Balcony
❑ Leading Edge
❑ Other:
❑ Safety Net: Must be installed within 30 feet vertical of the work surface
and must extend out from the outermost projection of the work surface:
Up to 5' Fall = 8 Feet Actual vertical fall distance:
5' to 10' Fall = 10 Feet
> 10' Fall = 13 Feet Actual net width:
A person falling into the net can't contact any object below the net. The
system must be tested or certified to withstand a 400 pound object
dropped from the highest work surface. Mesh at any point must not
exceed 36 square inches with the largest opening being 6" side to side.
Inspect weekly for mildew, wear or damage and remove any objects in net
as soon as possible.
Anchors points are:
Configuration and placement sketch attached: ❑ Yes ❑ No
Manufacturer’s installation instructions attached? ❑ Yes ❑ No
Additional Instructions:
❑ Roof > 4/12 Pitch
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Open Beam
❑ Truss/Top Plate
❑ Window Opening
❑ Open Sided Floor
❑ Deck / Balcony
❑ Leading Edge
❑ Scaffold Work
❑ Mobile Lift Work
❑ Ladder Work
❑ Excavation Edge
❑ Grade Drop-Off
❑ Other:
Fall protection methods Identified Fall hazards above 10 feet
Check all that apply
❑ Positioning Belt: A full body harness will be used with two lanyards
attached to “D” rings on each side of the employee’s waist. The employee
will attach both lanyards to an anchor point and be rigged to not be able to
fall more than 2 feet . The anchor must be able to sustain 2 times the
intended load or 3000 lbs whichever is greater. Snap hooks must not be
connected to each other or to loops in webbing.
Anchors points are:
Configuration and placement sketch attached: ❑ Yes ❑ No
Manufacturer’s installation instructions attached? ❑ Yes ❑ No
Additional Instructions:
❑ Roof > 4/12 Pitch
❑ Open Beam
❑ Truss/Top Plate
❑ Window Opening
❑ Ladder Work
❑ Work from Wall
❑ Other:
❑ Other Fall Protection System: Provide a description of how the
system is to be assembled, disassembled, operated, inspected and
maintained including specifications for materials to be used in its
construction:
❑ Roof > 4/12 Pitch
❑ Roof =< 4/12
Pitch
❑ Skylight Opening
❑ Roof Opening
❑ Floor Opening
❑ Open Beam
❑ Truss/Top Plate
❑ Window Opening
❑ Open Sided Floor
❑ Deck / Balcony
❑ Leading Edge
❑ Scaffold Work
❑ Mobile Lift Work
❑ Ladder Work
❑ Excavation Edge
❑ Grade Drop-Off
❑ Other:
Note: Fall protection systems will be assembled and maintained according to manufacturer's
instructions when using a manufactured system.
❑ A copy of those instructions are available on site for reference.
❑ Our fall protection systems will meet WISHA regulations as contained in WAC 296-155 Part
C-1 which is available on site as reference.
C. Protection Against Overhead Hazards
When employees are working at elevation, we will provide the following
protection(s) for employees working below:
❑ Require persons to wear hard hats ❑ Screens on Guardrails
❑ Overhead Hazard Signs ❑ Toe Boards on Guardrails
❑ Debris Nets ❑ Barricade to Control Access
❑ Other
Fall protection methods Identified Fall hazards above 10 feet
D. Handling Storing and Securing Tools and Materials
All personal fall protection equipment will be kept at to prevent
damage from weather and other sources. Damaged fall protection equipment
must be reported to the supervisor immediately and must be repaired or replaced
before employees may enter the area containing the fall hazard.
Tools used at elevations will be secured as follows:
❑ Tool belts will be used to carry hand tools. Tools will be returned to the belt after use.
❑ Tools too large for the tool belt will be raised by rope and pulley.
❑ Large tools which may fall to lower levels will be secured to rails and other fixed
objects where necessary.
❑ Other:
Building materials will be delivered to upper levels by the following methods:
Storage at elevation will not exceed 1 unit high.
Other Instructions:
E. Emergencies and Injuries
First Aid Trained Employee(s) on Site:
Name Name
First Aid Kit Location(s):
Nearest Medical Facility:
Emergency Services Phone Numbers:
Medical Fire Police
Location of Nearest Telephone:
If a crew member is injured at elevation, the supervisor will evaluate the
employee's condition and may voluntarily administer first aid. Emergency
services will be called as needed. If an injured employee can't return to ground
level the employee will be brought down to a lower level by emergency services.
The following equipment is available on site to help lower the injured worker:
F. Employee Training
We have explained this fall protection plan to each employee at the
job site. Employees who use personal fall protection equipment have
received training in its proper use and care. By signing this
document, the employees acknowledge that they understand the
plan and have been trained in the use of the equipment.
Name Signature Date
By signing below, the competent person certifies that the fall hazard
analysis has been done, the employees have been trained on the
plan and that employees have received training in how to use and
care for the personal fall protection equipment they were given:
Name Signature Date
City Assured Equipment Grounding Program Log
Month Year Color Code Project Number Location Page of
Type or
Name of
Equipment
Equipment
Identification
Number
Date of
Test
Type of
Test
Condition
of
Equipment
Sent for
Repair
Date of
Retest
Condition
at Retest
Returned
to Service
Badge #
Receiving
Equipment
Comments Inspector’s
Name
M - D - Y Lm 1 3 6 S / U M - D - Y M - D - Y S / U M - D - Y
BLOODBORNE PATHOGENS
Offer of Hepatitis B Vaccination Form
Hepatitis B Vaccine Acceptance
I understand that due to my occupational exposure to blood or other potentially infectious
materials, I may be at risk of acquiring Hepatitis A and/or B Virus infection when
responding to accidents, cleaning public restrooms and parks, and performing other
public service functions.
I certify or request one of the following:
[ ] I have completed the hepatitis B vaccine series.
[ ] I desire to be administered the hepatitis B vaccine series of three injections, at no cost
to me.
[ ] I am declining to submit to the hepatitis B vaccine series at this time. However, if at a
later date I desire to be vaccinated I shall continue to have this employer sponsored
opportunity, provided I remain in the status of a full-time, regular employee of the City.
Signature:________________________________________________
Printed Name:_______________________________________
Social Security Number (last 4 digits) ____________________________
Date:_______________
If employee is under 18 years of age, the parent or legal guardian must read and sign
below:
I certify that I am the parent or legal guardian of the employee above named; that I have
read and understood the form language; and that I grant my full consent and
authorization for the (consent/refusal) of the Hepatitis B vaccination series.
Parent (or) Legal Guardian signature: ___________________________________
Date:______
[Print Name) ____________________________________________________
Relationship to employee:____________________________________________
VACCINE ADMINISTERED RECORD:
Type Date Lot # Provider
Initial Vaccine
2nd in series
3rd in series
EXPOSURE INCIDENT INVESTIGATION FORM
Date of Incident: Time of Incident:
Location:
Potentially Infectious Materials Involved
Type: Source:
Circumstances (Work being performed, etc.):
How Incident was Caused (Accident, equipment malfunction, etc.):
Personal Protective Equipment Being Used:
Actions Taken (Decontamination, clean-up, reporting, etc.):
Recommendations for Avoiding Repetition:
Report Prepared By:
Job Title:
Date:
POST-EXPOSURE EVALUATION AND FOLLOW-UP CHECKLIST
The following steps must be taken and information transmitted in the case of an employee
being exposed to blood-borne pathogens:
Activity
Completion
Date
• Employee furnished with documentation regarding
exposure incident
• Source individual identified
(Name)
• Source individual’s blood tested and results
given to exposed employee
Consent could not be obtained
• Exposed employee’s blood collected and tested
• Appointment arranged for employee with health-care
Professional
Professional’s Name
• Documentation forwarded to healthcare professional
Blood-borne Pathogens Standard
Description of exposed
employee’s
duties
Description of exposure incident
Result of source individual’s
blood
Testing including routes of
exposure
Employee’s medical records
LOCKOUT/TAGOUT LOG
Project Site:
Page #:
Date
Applied:
Authorized
Employee: Location: System Locked Out: Date
Removed:
Authorized
Employee:
EMERGENCY LOCK REMOVAL PROCEDURES
Date: Time:
1) Name of LOTO device owner whose Lock/Tag is to be removed:
2) LOTO device owner's contact information:
3) LOTO device owner's AWS Supervisor:
4) Documented Attempt to Contact LOTO Device Owner:
Date/Time: Method of Contact: Result:
5) Purpose for
LOTO
Removal:
Evaluate the entire affected system to ensure employee’s safety before LOT device is removed.
Device Removal Verification
Removed By (Print): Observed
By (Print):
Signature: Signature:
Date/Time: Date/Time:
MEDICAL QUESTIONNAIRE FORM (Mandatory)
WAC 296-842-22005
To the employer:
• Must tell employee how to deliver or send the completed questionnaire to the health
care provider.
• Will not review employee’s questionnaire.
To the employee: Can you read? (Circle one): Yes/ No
• Your employer must allow you to answer this questionnaire during normal working
hours, or at a time and place that is convenient to you.
• Your employer or supervisor must not look at or review your answers at any time.
• Your employer must tell you how to deliver or send this questionnaire to the health
care professional who will review it.
To the Health care provider:
• Review information in this questionnaire and any additional information provided to
you by the employer
• You may add questions to this questionnaire; HOWEVER, questions in Parts 1-3 may
not be deleted or substantially altered.
• Follow-up evaluation is required for any positive response to questions 1-8 in Part 2, or
questions 1-6 in Part 3. This might include: phone consultations to evaluate positive
responses, medical tests, and diagnostic procedures
• When evaluation is complete, send a copy of your written recommendations to the
employer and employee.
Part 1. Employee Background Information (Mandatory) All employees must complete this
part.
1. Today’s date: ________________________
2. Your name: __________________________
3. Your age (to nearest year): ________________
4. Sex (circle one): Male/ Female
5. Your height: _______ft. ______in.
6. Your weight: ________lbs
7. Your job title: ________________________
8. A phone number where you can be reached by the health care professional who reviews
this questionnaire (include the area code): _______________________
9. The best time to reach you at this number: ______________________
10. Has your employer told you how to contact the health care professional who will review
this questionnaire (circle one): Yes/ No
11. Check the type of respirator you will use (you can check more than one category:
a. _______ N. R. or P. filtering-face piece respirator (for example, a dust mask, or an
N95 filtering-face piece respirator)
b. Check all that apply
Half Mask Full face piece mask Helmet hood Escape
Nonpowered cartridge or canister Powered air-purifying cartridge respirator
(PAPR)
Supplied air or Air-line
12. Have you worn a respirator (circle one): Yes/ No
If “yes” what type(s): ________________________
Part 2. General Health Information (Mandatory) All employees must complete this part.
Please circle “Yes” or “No”
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/
No
2. Have you ever had any of the following conditions?
a. Seizures (fits): Yes/ No
b. Diabetes (sugar disease): Yes/ No
c. Allergic reactions that interfere with your breathing: Yes/ No
d. Claustrophobia (fear of enclosed spaces): Yes/ No
e. Trouble smelling odors: Yes/ No
3. Have you ever had any of the following pulmonary or lung problems?
a. Asbestosis: Yes/ No
b. Asthma: Yes/ No
c. Chronic bronchitis: Yes/ No
d. Emphysema: Yes/ No
e. Pneumonia: Yes/ No
f. Tuberculosis: Yes/ No
g. Silicosis: Yes/ No
h. Pneumothorax (collapsed lung): Yes/ No
i. Lung cancer: Yes/ No
j. Broken ribs: Yes/ No
k. Any chest injuries or surgeries: Yes/ No
l. Any other lung problem that you’ve been told about: Yes/ No
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
a. Shortness of breath: Yes/ No
b. Shortness of breath when walking fast on level ground or walking up a slight hill or
incline: Yes/ No
c. Shortness of breath when walking with other people at an ordinary pace on level
ground: Yes/ No
d. Have to stop for breath when walking at your own pace on level ground: Yes/ No
e. Shortness of breath when washing or dressing yourself: Yes/ No
f. Shortness of breath that interferes with your job: Yes/ No
g. Coughing that produces phlegm (thick sputum): Yes/ No
h. Coughing that wakes you early in the morning: Yes/ No
i. Coughing that occurs mostly when you are lying down: Yes/ No
j. Coughing up blood in the last month: Yes/ No
k. Wheezing: Yes/ No
l. Wheezing that interferes with your job: Yes/ No
m. Chest pain when you breathe deeply: Yes/ No
n. Any other symptoms that you think may be related to lung problems: Yes/ No
5. Have you ever had any of the following cardiovascular or heart problems?
a. Heart attack: Yes/ No
b. Stroke: Yes/ No
c. Angina: Yes/ No
d. Heart failure: Yes/ No
e. Swelling in your legs or feet (not caused by walking): Yes/ No
f. Heart arrhythmia (heart beating irregularity): Yes/ No
g. High blood pressure: Yes/ No
h. Any other heart problem that you’ve been told about: Yes/ No
6. Have you ever had any of the following cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest: Yes/ No
b. Pain or tightness in your chest during physical activity: Yes/ No
c. Pain or tightness in your chest that interferes with your job: Yes/ No
d. In the past two years, have you noticed your heart skipping or missing a best: Yes/
No
e. Heartburn or indigestion that is not related to eating: Yes/ No
f. Any other symptoms that you think may be related to heart or circulation problems:
Yes/ No
7. Do you currently take medication for any of the following problems?
a. Breathing or lung problems: Yes/ No
b. Heart Trouble: Yes/ No
c. Blood Pressure: Yes/ No
d. Seizures (fits): Yes/ No
8. If you’ve used a respirator, have you ever had any of the following problems? (If you’ve
never used a respirator, check the following space and got to question 9):
a. Eye irritation: Yes/ No
b. Skin allergies or rashes: Yes/ No
c. Anxiety: Yes/ No
d. General weakness or fatigue: Yes/ No
e. Any other problem that interferes with your use of a respirator: Yes/ No
9. Would you like to talk to the health care professional who will review this
questionnaire about your answers to this questionnaire: Yes/ No
Part 3. Additional Questions for Users of Full-Face Respirators or SCBAs
Please circle “Yes” or “No”
1. Have you ever lost vision in either eye (temporarily or permanently): Yes/ No
2. Do you currently have any of the following vision problems?
a. Need to wear contact lenses: Yes/ No
b. Need to wear glasses: Yes/ No
c. Color blind: Yes/ No
d. Any other eye or vision problem: Yes/ No
3. Have you ever had an injury to your ears, including a broken eardrum: Yes/ No
4. Do you current have any of the following hearing problems?
a. Difficulty hearing: Yes/ No
b. Need to wear a hearing aid: Yes/ No
c. Any other hearing or ear problem: Yes/ No
5. Have you ever had a back injury: Yes/ No
6. Do you currently have any of the following musculoskeletal problems?
a. Weakness in any of your arms, hands legs or feet: Yes/ No
b. Back pain: Yes/ No
c. Difficulty fully moving your arms and legs: Yes/ No
d. Pain or stiffness when you lean forward or backward at the waist: Yes/ No
e. Difficulty fully moving your head up or down: Yes/ No
f. Difficulty fully moving your head side to side: Yes/ No
g. Difficulty bending at your knees: Yes/ No
h. Difficulty squatting to the ground: Yes/ No
i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/ No
j. Any other muscle or skeletal problem that interferes with using a respirator: Yes/
No
Part 4. Discretionary Questions (Health Care Provider driven) Questions in this section are
only required if the health care provider says they are necessary.
1.In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has
lower than normal amounts of oxygen: Yes/ No
If “yes”, do you have feelings of dizziness, shortness of breath, pounding in your chest, or
other symptoms when you’re working under these conditions: Yes/ No
2. Have you ever been exposed to (at work or at home) to hazardous solvents, hazardous
airborne chemicals (e.g. gases, fumes, or dust), or have you come in skin contact with
hazardous chemicals: Yes/ No
If “yes,” name the chemicals if you know them:
____________________________________________________________
3. Have you ever worked with any of the materials, or under any of the conditions listed
below?
a. Asbestos: Yes/ No
b. Silica (e.g. in sandblasting): Yes/ No
c. Tungsten/cobalt (e.g. grinding or welding this material): Yes/ No
d. Beryllium: Yes/ No
e. Aluminum: Yes/ No
f. Coal (for example, mining): Yes/ No
g. Iron: Yes/ No
h. Tin: Yes/ No
i. Dusty environments: Yes/ No
j. Any other hazardous exposures: Yes/ No
If “yes,” describe these exposures: ____________________________________________________
4.List any second jobs or side businesses you have: _____________________________________
5. List your previous occupations: ____________________________________________________
6. List your current and previous hobbies: ______________________________________________
7. Have you ever been in the military services? Yes/ No
If “yes,” were you exposed to biological or chemical agents (either in training or combat): Yes/
No
8. Have you ever worked on a HAZMAT team? Yes/ No
9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and
seizures mentioned earlier in this questionnaire, are you taking any other medications for any
reason (including over-the-counter medications): Yes/ No
If “yes,” name the medication if you know them: ______________________________________
10. Will you be using any of the following items with your respirator(s)?
a. HEPA Filters: Yes/ No
b. Canisters (for example, gas masks): Yes/ No
c. Cartridges: Yes/ No
11. How often are you expected to use the respirator(s)? (Circle “yes” or “no” for all answers
that apply to you)
a. Escape only (no rescue): Yes/ No
b. Emergency rescue only: Yes/ No
c. Less than 5 hours per week: Yes/ No
d. Less than 2 hours per day: Yes/ No
e. 2 to 4 hours per day: Yes/ No
f. Over 4 hours per day: Yes/ No
12. During the period you are using the respirator(s), is you work effort:
a. Light (less than 200kcal per hour): Yes/ No
If “yes,” how long does this period last during the average shift: _____hrs. ____mins.
Examples of a light work effort are sitting while writing, typing, drafting, or performing
light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling
machines.
b. Moderate (200 to 350 kcal per hour): Yes/ No
If “yes,” how long does this period last during the average shift: _____hrs. _____mins.
Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus
in urban traffic; standing while drilling , nailing, performing assembly work, or
transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about
2 mph or down a 5-degree grade at 3 mph; or pushing a wheelbarrow with a heavy load
(about 100 lbs.) on a level surface.
c. Heavy (above 350 kcal per hour): Yes/ No
If “yes,” how long does this period last during the average shift: _____hrs. _____mins.
Examples of heavy work are lifting a heavy load (about 50 lbs) from the floor to your waist
or shoulder, working on a loading dock, shoveling, standing while bricklaying or chipping
castings, walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load
(about 50 lbs.).
13. Will you be wearing protective clothing and/or equipment (other than the respirator)
when you’re using your respirator: Yes/ No
If “yes,” describe this protective clothing and/or
equipment:_____________________________
14. Will you be working under hot conditions (greater than 77 F): Yes/ No
15. Will you working under humid conditions: Yes/ No
16. Describe the work you’ll be doing while you’re using your
respirator(s):________________________
17. Describe any special or hazardous conditions you might encounter when you’re using your
respirator(s) (for example, confined spaces, life-threatening gases):
____________________________
18. Provide the following information, if you know it, for each toxic substance that you’ll be
exposed to when you’re using your respirator(s):
Name of the first toxic substance: ______________________________
Estimated maximum exposure level per shift:
__________________________________
Duration of exposure per shift ________________________________
Name of the second toxic substance: ______________________________
Estimated maximum exposure level per shift:
__________________________________
Duration of exposure per shift ________________________________
Name of the third toxic substance: ______________________________
Estimated maximum exposure level per shift:
__________________________________
Duration of exposure per shift ________________________________
The name of any other toxic substances that you’ll be exposed to while using
your respirator:
__________________________________________________________
19. Describe any special responsibilities you’ll have while using your respirator(s) that may
affect the safety and well-being of others (for example, rescue, and security):
______________________________________________________________________________
_______________________________ _________________________
Signature Date
MEDICAL PROVIDER’S LETTERHEAD
To: The City of Port Townsend
250 Madison St.
City of Port Townsend, WA 98368
Date: _______________________________
To whom it may concern:
I have reviewed _____________________________________________________
Questionnaire and he/she is: (CHECK THE APPROPRIATE BOX)
CLEARED FOR RESPIRATOR USE
NOT CLEARED FOR RESPIRATOR USE
REQUIRES FURTHER MEDICAL EVALUATION BEFORE RESPIRATOR
USAGE CAN BE DETERMINED
Sincerely,
____________________________________
Printed Name of Medical Professional
____________________________________
Signature of Medical Professional
EMPLOYER PROVIDED INFORMATION FOR MEDICAL EVALUATIONS
The WISHA Respirators Rule (WAC 296-842) requires that certain information
regarding respirator use be provided by the employer to the licensed health care
provider (LHCP). The following general information must be provided to the LHCP
by the employer:
• A copy of our written respiratory protection program;
• A copy of the Respirators Rule WAC 296-842.
In addition, certain respirator user-specific information must be provided. This form
may be used by the employer to provide the respirator user specific information to the
LHCP, but is not a required form.
Specific Respirator Use Information for Respirator Use Medical Evaluation
Employee Name: ___________________________________________________________
Employer name: ____________________________________________________________
Employee job title: __________________________________________________________
Employer Address: _________________________________________________________
City contact person and phone #: _____________________________________________
1. Will the employee be wearing protective clothing and/or equipment (other than
the respirator) when using the respirator?
Yes/No __________ If “yes,” describe this protective clothing and/or
equipment:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Eye Protection, hearing protection, rain gear (pants and jacket), Hard Hat and
Gloves. These are items that maybe used but all may not be used at the same
time.
2. Will employee be working under hot conditions (temperature exceeding 77
degrees F)?
Yes/No __________ If “yes”, describe temperature and duration.
________________________________________________________________________
________________________________________________________________________
3. Will employee be working under humid conditions? Yes / No __________
4. Describe any special or hazardous conditions you might encounter when you're
using your respirator(s) (for example, confined spaces, life-threatening gases).
Can be used in Confined Spaces but not in life-threatening situations.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Specific Respirator Use Information, Continued
Table 1: Specific Respiratory Use Information
Check
Appropriate
Box
Respirator
Type
Face / Head
Cover Type
(i.e. 1/2 or full
face, helmet,
hood)
Frequency of Use
(i.e. hours / day, week,
month)
Work Effort
Light,
Moderate,
Heavy
(see
descriptions
below)
Respirator
Weight
Disposable
face-piece
particulate
filter
(N, R or P
series)
1/2 face-piece Once or twice a year Moderate
Mask with
replaceable
filter or
cartridge
1/2 face-piece Once or twice a year Moderate
Mask with
canister
Powered air-
purifying
respirator
(PAPR)
Air-line,
continuous
flow
Air-line,
negative
pressure
demand
Air-line,
positive
pressure
demand
SCBA,
negative
pressure
demand
Full face-piece
SCBA,
positive
pressure
demand
Full face-piece
Work Effort Descriptions
Examples of a light work effort are sitting while writing, typing, drafting, or
performing light assembly work; or standing while operating a drill press (1-3 lbs.) or
controlling machines.
Examples of moderate work effort are sitting while nailing or filing; driving a truck
or bus in urban traffic; standing while drilling, nailing, performing assembly work,
or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level
surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a
wheelbarrow with a heavy load (about 100 lbs.) on a level surface.
Examples of heavy work effort are lifting a heavy load (about 50 lbs.) from the floor
to your waist or shoulder; working on a loading dock; shoveling; standing; standing
while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph;
climbing stairs with a heavy load (about 50 lb.).
WAC 296-842-11005
Advisory Information for Employees Who Voluntarily Use Respirators
• Respirators protect against airborne hazards when properly selected and
used. WISHA recommends voluntary use of respirators when exposure to
substances is below WISHA permissible exposure limits (PELs) because
respirators can provide you an additional level of comfort and protection.
• If you choose to voluntarily use a respirator (whether it's provided by you or
your employer) be aware that respirators can create hazards for you, the user.
You can avoid these hazards if you know how to use your respirator properly
and how to keep it clean. Take these steps:
- Read and follow all instructions provided by the manufacturer about
use, maintenance (cleaning and care), and warnings regarding the
respirator’s limitations.
- Choose respirators that have been certified for use to protect against
the substance of concern. The National Institute for Occupational Safety
and Health (NIOSH) certifies respirators. If a respirator isn't certified by
NIOSH, you have no guarantee that it meets minimum design and
performance standards for workplace use.
• A NIOSH approval label will appear on or in the respirator
packaging. It will tell you what protection the respirator
provides. Keep track of your respirator so you don't mistakenly
use someone else’s.
Do not wear your respirator into:
• Required use situations when you are only allowed voluntary use.
• Atmospheres containing hazards that your respirator isn't
designed to protect against. For example, a respirator designed
to filter dust particles won't protect you against solvent vapor,
smoke, or oxygen deficiency.
Employee’s Signature Date
Respiratory Protection Training & Fit Testing Checklist
To be completed prior to training and fit testing:
□ Ensure that wearer has been medically cleared and approved to wear a
respirator
□ Ensure that wearer is clean shaven and is wearing the PPE that they would
wear with the respirator (clean shaven means no more than a mustache to the
corners of the mouth and a patch under the bottom lip, no facial hair can come
into contact with the respirator seal)
□ Have wearer fill out fit test form (see Attached)
□ Hand wearer a respirator, show them how to conduct positive and negative
pressure fit checks and have them check the size for proper fit
□ Once it is determined that the respirator appears to fit, have the wearer adjust
the straps and put the respirator on their face ensuring that the straps are snug
(not tight) and evenly adjusted
□ Make sure wearer can demonstrate the following knowledge and skills
required by their duties:
□ Have wearer perform positive and negative pressure seal checks (instruct
wearer that this is to be done each time the respirator is donned or adjusted)
□ Have wearer install P100 filters and wear the respirator while training ensues
to warm up the seal on the face
□ Inform the user on the respirator’s capabilities and limitations. Include, for
example, how the respirator provides protection and why air-purifying
respirators can’t be used in oxygen-deficient conditions
□ Train wearer on proper fit and adjustment of the respirator
□ Train wearer on the inspection of the respirator for damage, wear or missing
parts
□ Instruct wearer how to clean the respirator properly, both daily cleaning and a
more comprehensive cleaning
□ Inform wearer of respirator storage requirements
□ Instruct wearer on cartridge or filter selection and change-out schedules
□ Have wearer complete the remainder of the fit test form and sign in all three
places upon completion of training and passing the fit testing exercises
□ Double check paperwork to ensure that it is completed properly, make a copy
for our records and give the original to the appropriate customer contact
□ Important – Conduct sensitivity check using Bitrex or Stannic Chloride on user
before and after test to ensure that they can sense the test agent
Make sure employees can demonstrate the following knowledge and skills as
required by their duties: (each test should last one minute)
1 – Normal breathing 2 – Deep breathing 3 – Normal breathing while
nodding head up and down
4 – Normal breathing while gently turning head from side to side
5 – Reading the “Rainbow Passage” or counting out loud backwards from 100
6 – Bend at the waist (Run in place if fit testing with anything other than irritant
smoke)
RESPIRATOR FIT TEST RECORD
EMPLOYEE HAS HAD A MEDICAL REVIEW AND HAS NO LIMITATIONS THAT
WOULD PREVENT THE USE OF RESPIRATORY PROTECTION EQUIPMENT:
_________________________________________
Signature of person tested
A. EMPLOYEE NAME: ___________________________________ DATE: ____________
EMPLOYEE JOB TITLE/DESCRIPTION: ______________________________________
B. EMPLOYER NAME:
_______________________________________________________________________
LOCATION/ADDRESS:
______________________________________________________________________
TELEPHONE: ________________________________ FAX: ________________________
C. RESPIRATOR SELECTED:
__________________________________________________________________
MANUFACTURER: _____________________________MODEL/SIZE: _________________
NIOSH APPROVAL NUMBER: ___________________________
D. CONDITIONS WHICH COULD AFFECT RESPIRATOR FIT:
CLEAN SHAVEN FACIAL SCAR PPE WORN
COMMENTS/OTHER:
_________________________________________________________________
E. FIT CHECKS: NEGATIVE PRESSURE:
POSITIVE PRESSURE:
F. FIT TESTING QUALITIVE: BITREX IRRITANT SMOKE SACCHARINE
QUANTITATIVE: FIT FACTOR _______________
PASSED FAILED
F. EMPLOYEE ACKNOWLEDGEMENT OF TEST RESULTS:
EMPLOYEE SIGNATURE: _________________________________________ DATE: _____
TEST CONDUCTED BY: __________________________________________ DATE: ____
----------------------------------------------------------------------------------------------------------------------------
DISCLAIMER: This respirator fit test(s) training was performed on and by the person listed.
The results indicate the performance of the listed respiratory protective device under
controlled conditions, as tested on the employee named. Fit testing, as performed, meas ures
the ability of the respiratory protective device to provide protection to the individual tested.
The manufacturer or test conductor express or imply no guarantee that this or any identical
respiratory protective device will provide adequate protection under conditions other than
were present when this test was performed. Improper use, maintenance, or application of this
or any other respiratory protective device will reduce or eliminate protection.
___________________
Initials of person tested
Safe Behavior Observation Card
Observer’s Name: Time & Date:
Project Name:
Location of Work
Place a checkmark next to “At Risk” Behaviors and/or Conditions
At Risk Behavior or Condition Please Describe “At Risk”
Behavior/Condition:
☐ PPE in use for task
☐ Mobile Equipment
☐ Electrical
☐ Lockout/Tagout
☐ Work Permits
☐ Excavations
☐ Manual Lifting
☐ Ladders/Scaffolding
☐ Pre-task planning
☐ Body Positioning
☐ Aerial Lifts
☐ Barricading
☐ Slips/Trips/Falls
☐ Rigging
☐ Crane Operations
☐ Confined Spaces
☐ Tooling
☐ Housekeeping
☐ Follow-Up Required
Potential Severity (if applicable): ☐ Serious ☐ Minor ☐ Minimal ☐ Ergonomic
Significant Aspects of Observation and Discussion with Employees
Observer Signature:
Supervisor Signature:
Health and Safety Deficiency Tracking Log
Date
Description
Person responsible for
correcting deficiency
Projected
Resolution Date
Date
Resolved
Safety Committee/Safety Meeting Documentation Form
Use with WAC 296-800-130 Safety Committees and Safety
Meetings This form can help document the minutes of safety committees and
safety meetings in your workplace. This particular form isn’t required, but
shows the kind of information you need for your records. You can either copy
this form or make your own.
Agenda:
Review of minutes of last meeting:
Approved? Corrections:
Yes No
o
1. Unfinished business from last
meeting:
Any hazards reported during this time period?
Describe any accident investigations conducted since last meeting.
Did you identify and correct the cause of the unsafe situation(s)?
4. Is your accident and illness prevention program
working?
Yes No
5. What other safety-related topics did you cover in this meeting?
Employer: Worksite location:
Date: Meeting Start Time: Meeting End Time:
Who attended this
meeting?
Minutes written by:
Meeting Leader:
Next meeting will be on (date):
Next meeting location: