Occupational Health Program Risk Assessment and Training Assignment Form

advertisement
Occupational Health Program
Risk Assessment and Training Assignment Form
Name
Job Description
Department_________________
Phone Number
Date
______________________________________________
PI/ Supervisor
Email address _________________________________________________________________
 Faculty/Staff  Graduate Student Work Study  Student  Visitor/Contractor  other non-CSU
Risk Categories: Check all that apply
*Animal contact is defined as contact with animals, their unfixed tissues, fluids, wastes, equipment used in
caring for animals or frequent entry into an animal facility (i.e. caging, anesthesia, biosafety, HVAC, cagewash)
 Category 1: Administrative
 Category 2: Maintenance (i.e. facilities, housekeeping, equipment maintenance or repair )
 Category 3: Direct contact* with small animals (i.e. rodents, rabbits, dogs, cats, non mammals)
List the species in this category that you will work with:
Frequency:  Daily
Weekly
Monthly
Yearly
 Category 4: Direct contact* with large animals (i.e. livestock, sheep, horses)
List the species in this category that you will work with:
Frequency:  Daily
Weekly
Monthly
Yearly
Category 5: Biosafety level 2 (BSL-2) research and or Animal Biosafety level 2 (ABSL-2).
List BSL-2 organisms:
 Category 6: Biosafety level 3 (BSL-3) research and or Animal Biosafety level 3 (ABSL-3)
List the BSL 3 organisms:
 Category 7: Field Studies requiring the capture and contact* with live, wild animals
List the species in this category that you will work with:
Frequency:  Daily
Weekly
Monthly
Yearly
 Category 8: Direct contact with non-human primate tissues
 Category 9: Animal research involving viable recombinant DNA-containing microorganisms that require BSL-3
containment
 Category 10: Large-scale research or production (>10L) activities involving viable organisms containing
recombinant DNA molecules which require BSL-3 containment
List the BSL-3 organisms that you will work with:
 Category 11: Radiation exposure
 Non Ionizing {MRI, Lasers (Class IIIb & IV)}
 Ionizing (X-rays and radioactive materials)
 Category 12: Chemical exposures; check all that apply:
 4-Nitrobiphenyl  alpha-Naphthylamine  methyl chloromethyl ether  3,3'-Dichlorobenzidine
 bis-Chloromethyl ether  beta-Naphthylamine  Benzidine  4-Aminodiphenyl
 Ethyleneimine  beta-Propiolactone  2-Acetylaminofluorene  4-Dimethylaminoazo-benzene
 N-Nitrosodimethylamine  Vinyl chloride  Inorganic Arsenic  Lead  Cadmium  Benzene
1,2-dibromo-3-chloropropane  Acrylonitrile  Ethylene oxide  Formaldehyde
 Methylenedianiline
 Category 13: Allergens
 Dust  Pollen Animal Dander  Animal bedding  Animal excrement
 Category 14: Airborne Exposure, respirator used:
 Dust mask  Surgical mask Particulate (N95, R95)  Air Purifying Half Mask
 Air Purifying Full Facepiece  Powered air purifying  Airline (pressure demand or continuous flow )
 Self-contained breathing apparatus
 Category 15: Noise
 Barking Dogs  Pigs  Vacuum  Mechanical  Other
 Category 16: Human blood, tissue, or cell culture
 Are you Hepatitis B vaccinated?
Category 17: Emergency Responder, Police, Health Care Professional
 Category 18: Physical stress
 Repetitive motion
 Heavy lifting  Welding
Retain a copy for your records, and return the completed form to:
Joni Triantis Van Sickle
Environmental Health Services, 6021 Campus Delivery, Fort Collins, CO 80523
[email protected]
Download
Related flashcards
Create Flashcards