Laboratory Request for Respirator Use (Airborne Hazard) Evaluation
This form is to be used by laboratory Principle Investigators (PI) to request that EHS conduct an airborne hazard evaluation of an operation(s). An airborne hazard evaluation must be
performed for each operation where overexposure to a hazardous airborne material is possible during routine operations or where respirator use will be allowed. The PI needs to
provide the information requested below for each operation to be evaluated and send the request by campus mail to the EHS office 100 EHS (Attention: LuAnn Hiratzka) or drop off
the form at 122 Grand Avenue Court. Use more than one sheet if more than three materials handled with mask use.
Laboratory Building/Room Number
Lab Location
where Mask is
Used
Chemical
____________________________ PI
Suspected
Hazard
Task Where Mask is Used
Weighing
Dissolution; list liquid/solvent:
____________________________
Quantity/Concentration
Handled
once per day or less
Multiple times per day
_____times per
wk/mo/yr (circle)
Other, state
Estimate:
once per day or less
Multiple times per day
_____times per
wk/mo/yr (circle)
Other, state
Estimate:
once per day or less
Multiple times per day
_____times per
wk/mo/yr (circle)
Other, state
Liquid/solvent transfer
Other - Describe other activities
involving this chemical
Weighing
Dissolution; list liquid/solvent:
Frequency of Use
Estimate:
Liquid/solvent transfer
Other - Describe other activities
involving this chemical
Weighing
Dissolution; list liquid/solvent:
Exposure
Time
Liquid/solvent transfer
Other - Describe other activities
involving this chemical
Please circle or check next to all materials (regulated by OSHA) listed below that are used in the lab –
Methylene chloride, 75-09-2
4-Nitrobiphenyl, 92933
alpha-Naphthylamine, 134327
Methyl chloromethyl ether, 107302
3,3'-Dichlorobenzidine (and its salts), 91941
bis-Chloromethyl ether, 542881
beta-Naphthylamine, 91598
Benzidine, 92875
4-Aminodiphenyl, 92671
Ethyleneimine, 151564
beta-Propiolactone, 57578
2-Acetylaminofluorene, 53963
4-Dimethylaminoazo-benzene, 60117
N-Nitrosodimethylamine, 62759
Vinyl chloride, 75014
Arsenic (Inorganic and its compounds), 7440-38-2
(arsenic)
Lead (Inorganic and its compounds), 7439-92-1 (lead)
Chromium (VI) forms, compounds
Cadmium and its compounds, 7740-43-9 (cadmium)
Benzene, 71-43-2
Formaldehyde (& substances releasing formaldehyde),
50-00-0 (formaldehyde)
1,2-Dibromo-3-chloropropane (DBCP), 96-12-8
Acrylonitrile, 107-13-1
Ethylene oxide (EtO), 75-21-8
Methylenedianiline, 101-77-9
1,3-Butadiene (BD), 106-99-0
Asbestos
Raw cotton dust
Coke oven emissions