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 joni.triantis@colostate.edu