EMPLOYEE APPLICATION FOR PROTECTIVE EYEWEAR
(Please print or type)
UMKC DEPARTMENT OF ENVIRONMENTAL HEALTH AND SAFETY
REVISION 2016
Name: ________________________________________________ Empl Id #: __________________________________
Department: _______________________________________ Job Title: _______________________________________
Indicate with an “X” in the following chart the eye hazards the employee is exposed to.
TYPE OF EXPOSURE
RISK ANALYSIS
EYE PROTECTION GUIDE (see table-1)
Light Exposure
X Severe Exposure
Hot Molten Metals
Milling, sawing, turning, shaping, cutting,
grinding or stamping of Solid Materials
Heat treatment, tempering, or kiln firing
Welding
Vehicle repair & servicing
Caustic or explosive materials handling.
Chemical, splash, dust, …
Injurious radiation
Other
A
A+B
A
A+D
C (gas)
A or B
A+D or B
A+D
E (arc)
A or B
A or B
Consult Radiation
Safety Officer
Describe below
A+D or B+D
Consult Radiation
Safety Officer
Describe below
X
Average
Exposure
Hrs/wk
Employee’s Signature: _______________________________________________ Date: ___________________________
SUPERVISOR/DEPARTMENT HEAD MUST COMPLETE THIS SECTION:
Indicate with an “X” in the following chart the type of eyewear you are approving for your employee.
TYPE
A
A
B
C
D
E
PROTECTIVE EYEWEAR APPROVAL
EYE PROTECTION GUIDE (see table-1)
Prescription Safety Glasses
Plano Safety Glasses
Splash Goggles
Welding Goggles (gas)
Face Shield
Welding Helmet (arc)
X
Supervisor’s Name: ____________________________________________ Date: ____________________________
Supervisor’s Signature: _________________________________________ Ph. #: ____________________________
MoCode: ______________________________________ Requesting prescription glasses? Yes ______ No _______
For prescription eyewear, submit this completed form to the Environmental Health and Safety department by email:
(leutzingerw@umkc.edu) or FAX: (816)235-6559. The employee will then present their prescription to the Sutherlin
Optical facility located in the Crossroads Art district.
Sutherlin Optical
1941 Central, KC, MO. 64108
ph. (816)421-0369
hours: M – F
8:30am – 5:00pm
TABLE - 1