QUESTIONNAIRE ABOUT RISKS AT WORK
DATE (dd/mm/yyyy)
UPDATES
FAMILY NAME
First name:
Work address:
UNIT:
TEAM:
Building:
Floor:
Tel.:
Room (s):
Email:
CATEGORY
RESEARCHER
ENGINEER
TECHNICIAN
ADMINISTRATIVE
GRADUATE STUDENT
POST-DOTORAL FELLOW
OTHER (specify):
STATUS
TENURED CIVIL SERVANT
INTERN CIVIL SERVANT
FIXED-TERM CONTRACT
TEMPORARY WORKER
OTHER (specify) :
RESEARCH AREA(S) AND TECHNIQUE(S) USED
PRIOR EXPOSURE(S)
Questionnaire about risks at work
Other (specify):
DRH/BCMP/22.10.2015
Asbestos
Aromatic amines
Arsenic and derivatives
Benzene
Bis-chloromethylether
Vinyl chloride
Chromium
Petroleum-derived mineral oils
Nickel
Nitrosoguanidines
Iron oxide
Wood dust
Ionising radiation
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"USER" INSTRUCTIONS
This questionnaire is designed to determine your risks and working conditions in a consultation with the Prevention Physician,
with a view to tailoring your medical surveillance.
If you find it difficult to answer any items, bring them up with the physician at the beginning of the consultation.
To fill in this questionnaire:
 Tick the working conditions that apply to you directly or indirectly as well as any toxic products you are exposed to.
 This will be updated at every medical visit. This information should be amended if you are no longer being exposed to a risk
or if you are being exposed back to a risk.
QUESTIONNAIRE
1/ OCCUPATIONAL BACKGROUND
1-1/ USUAL WORKING SITUATIONS
Air-conditioning
Noisy environment
Driving
Contact with patients
Frequent contact with the general public
Repetitive movements
Handling of biological waste
Handling of chemical waste
Handling of radioactive waste
Warehousing, heavy loads
Trips abroad
Stressful postures
Work in blind premises
Meticulous work
Hot and/or damp working environment
Work in a cold environment or cold room
Animal house
Washroom
Solitary work
In front of a screen >4 hours
Work with composite materials (plastics, resins, etc.)
Other (specify):
1-2/ MATERIALS AND INSTRUMENTS
Aerosol generators
Machines that vibrate
High-pressure machines (autoclave, etc.)
Glove box
Mobile sensor (e.g. "Boa")
Centrifugation
ETRAF (chemical hood)
Cryogenic fluid
Oven, microwave, incubator
Compressed or liquefied gas
Inflammable gas
HPLC
Sharp instruments
Electron microscope
Light microscope
Microtomes, cryostats
Biosafety cabinet
Automatic sequencer
Cell sorter
Other (specify):
DRH/BCMP/22.10.2015
REMARKS AND COMMENTS:
Questionnaire about risks at work
2/8
2/ BIOLOGICAL RISKS
2-1/ HANDLING ANIMALS
Types
Pathogen-free
facility
Wild
(not obtained from
a breeding facility)
Deliberately infected
with a
pathogen
GMO
Rodents
Specify :
Humanized SCID
Specify :
Primates :
Specify :
Other (Specify) :
2-2/ ANIMAL-DERIVED BIOLOGICAL PRODUCTS
Species
Rodents
Primates
Other (Specify):
Fluids, tissues, homogenate or primary culture
Tumor
Blood, blood cells, serum
Other (Specify) :
Carrying a human pathogen (natural or deliberate infection)
Specify:
Containing a GMO or derived from a transgenic animal ?
Specify:
Culture of commercially available cell lines
Not pathogenic for humans
Culture containing a human pathogen (deliberate inoculation)
Specify:
Transfected or containing a GMO
Specify:
Culture of cells immortalized in the laboratory
Immortalization method (specify) :
2-3/ BIOLOGICAL PRODUCTS FROM A HUMAN SOURCE
Fluids, tissues, homogenate or primary culture
Tumor
Blood, blood cells, serum
Other (specify) :
Carrying a human pathogen (natural or deliberate infection)
Specify:
Traceability
Culture of commercially available cell lines
Not pathogenic for humans
Culture containing a human pathogen (deliberate inoculation)
Specify:
DRH/BCMP/22.10.2015
Transfected or containing a GMO
Specify:
Culture of cells immortalized in the laboratory
Immortalization method (specify):
Questionnaire about risks at work
3/8
2-4/ BIOLOGICAL AGENTS
Biological agents
Not pathogenic
Pathogenic
Bacteria
Name (s) :
Viruses
Nom(s) :
Parasites
Name (s) :
Fungi and yeasts
Name (s) :
Prions
Which?
Viral vector
Adenovirus
Retrovirus
Lentvirus
Poxvirus (cowpox, etc.)
Other (herpesvirus, baculovirus, chimeric vectors, AAV, etc) specify:
2-5 / CONFINEMENT LEVEL
Level
1
2
3
4
Laboratory
Animal house
2-6 / OTHER RISKS
Plant handling
Specify:
Handling biological waste
Specify:
Toxins or venoms
Specify:
2-7 / CONTACT WITH PATIENTS
Specify:
DRH/BCMP/22.10.2015
REMARKS AND COMMENTS:
Questionnaire about risks at work
4/8
3/ PHYSICAL AGENTS
Type of ionizing radiation
Radiation β
Radiation 
X rays
Neutrons
Synchrotron radiation
External exposure
Internal exposure (incorporation)
Ionizing radiation from a generator
Sealed sources
Common radioactive elements in unsealed
sources
3 H ()
14 C ()
18 F
P ()
P ()
35 S ()
36 CI ()
45 Ca ()
47 Ca ()
64 Cu
67 Cu
111 In
123 I (,X)
125 I ()
129 I (,)
131 I (,)
Radioactive elements in sealed or unsealed
sources
22 Na (,)
24 Na (,)
51 Cr ()
55 Fe (X)
32
33
Fe (,)
()
Other naturally occurring radioactive elements
Other radioactive elements
Category B
Category A
59
99m Tc
Instrument with a built-in laser
Laser set-up (according to Class)
1
1M
2
2M
3A
3B
4
Lasers (according to wavelength )
UV-C (100 - 280 nm)
UV-B (280 - 315 nm)
UV-A (315 - 400 nm)
Visible (400 - 760 nm)
IR-A (760 - 1400 nm)
IR-B (1400 - 3000 nm)
IR-C (3000 - 106 nm)
Lasers (according to operating mode)
Continuous
Pulsed
Non-ionizing radiation
Infrared radiation
UV radiation
Ultrasound (sonicator, etc.)
Electromagnetic fields
Very low and low frequency
(0 - 10 kHz: powerful electrical installation)
Radiofrequency
(10 kHz - 300 MHz: induction oven, radio, TV)
Hyper frequency
(300 MHz - 300 GHz: antenna, mobile
telephone, radar, microwave oven)
Static magnetic fields
NMR
Other
DRH/BCMP/22.10.2015
REMARKS AND COMMENTS:
Questionnaire about risks at work
5/8
4/ CHEMICALS
Ethyl acetate
Ethers, glycols and glycol ethers
Ethylene glycol
Ethyl ether
1,4 Dioxane C2
Tetrahydrofurane (THF)
Ketones
Acetone
Amines, amides and nitrogenated solvents
Aniline and salts C2 M2
Dimethylaniline C2
Pyridine (IARC Gr 3)
Piperidine
Acetonitrile
Acrylonitrile C1B
Formamide R1B
Dimethylformamide (DMF) R1B
N-methylformamide R1B
Acetamide C2
N-methylpyrrolidone (NMPO) R1B
Diverse solvents
Carbon sulphide R2
Dimethylsulphoxide (DMSO)
Tetrahydrothiofurane-1,1-dioxide, Sulfolane
Halogenated compounds
2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) (IARC Gr1)
Iodoacetamide
Diisopropyl fluorophosphate DIFP
Phenylmethylsulphonylfluoride PMSF
Fluoro-1-dinitro-2,4-benzene
Dichloro-1,3-propanol C1B
Questionnaire about risks at work
Phenols, quinones
Phenol M2
Hydroquinone C2 M2, benzoquinones
Aldehydes and carbonyl compounds
Formaldehyde (formol) C2
Paraformaldehyde C2
Glutaraldehyde
Glyoxal M2
Diethyl pyrocarbonate (DEPC)
Dimethyl pyrocarbonate (DMPC)
Aliphatic amines
Ethylene diamine
Other (specify) :
Aromatic amines
Benzidine and salts C1A
Dichlorobenzidine C1B
Diamino-3,3'-benzidine (DAB) and salts C1B M2
Tetramethyl-3,3’,5,5’-benzidine and salts M2
o-phenylene diamine C2 M2
4-methyl-o-phenylenediamine C1B M2
o-toluidine (4,4'-methylene-di-o-toluidine) and salts
C1B
Other aromatic amines (specify):
Hydrazine and derivatives
Hydrazine and salts C1B
Nitrosamines, amides, nitroso-ureas and guanidines
Specify:
Alkylating agents
Dimethyl sulphate (DMS) C1B M2
Ethyl carbamate (urethane) C1B
Intercalating agents
Ethidium bromide (BET) M2
Acridine orange M2
Ethidium propyl EDTA assimilated M2
Methidium propyl MDTA assimilated M2
Propidium iodide
SYBR green
SYBR safe
Other intercalating agents (specify):
Stains and cold probes
Trypan Blue C1B
Acid Red 26 M2
Amino-3-ethyl-9-carbazole C1B
Crystal Violet C2
Amidoblack 10 B
Other stains (specify):
DRH/BCMP/22.10.2015
Aliphatic hydrocarbons
n-Hexane R2
n-Heptane
Cyclohexane
Petroleum ethers
Aromatic hydrocarbons
Benzene C1A M1B
Toluene R2
Xylenes (IARC Gr3 )
d, l, limonene (IARC Gr3 )
Halogenated hydrocarbons
Methylene chloride (dichloromethane) C2
Chloroform C2
Carbon tetrachloride C2
Trichlorethylene C1B M2
Other halogenated solvents
Alcohols and esters
Methanol
Ethanol (IARC Gr 1)
Isopropanol
Mercaptoethanol
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Promoters
Pristane
Okadaic acid
Retinoic acid R1B
Phorbol esters
Other promoters (specify):
Monomers and resins
Acrylamide C1B M1B R2
Bis-acrylamide
Methyl acrylate
Methyl methacrylate
Epoxy
Ethylene oxide C1B M1B
Strong oxidizing agents
Hydrogen peroxide (IARC Gr 3)
Active Cl bleach
Acids
Hydrochloric acid
Hydrofluoric acid
Nitric acid
Suplhuric acid (IARC Gr 1)
Osmium tetroxide
Acetic acid
Trichloroacetic acid (TCA)
Other acids (specify):
Arsenic and derivatives
Pure arsenic
Arsenic acid and salts C1A
Cacodylic acid-cacodylate (IARC Gr 2B)
Cyanide and derivatives
K or Na cyanide
Hydrocyanic acid
Cyanogen bromide
Sodium azide
Sodium nitrite
Propylene oxide C1B M1B
Isocyanates (methyl isocyanate: R2)
Other (specify):
Cytostatics (specify) :
Detergents
Sodium dodecylsulphate (SDS)
Other detergents (specify)
Diverse products
Thiourea C2 R2
Other organic products
Specify:
Cadmium
Cadmium chloride C1B M1B R1B
Chromium
Alkaline bichromate and sulphochromic mixture C1B
M1B R1B
Mercury derivatives
Mercuric chloride M2 R2
Other mercury derivatives (specify):
Nickel derivative
Metallic nickel C2
Other (specify):
Lead derivatives
Metallic lead
Other lead compounds R1A (specify):
Mineral fibers
Asbestos C1A
Ceramic fibers C1B
Mineral wool C2
Other mineral fibers (specify):
Silicium compounds
Crystalline silica (IARC Gr1)
Silanes
Actinides and derivatives
Uranyl acetate (specify):
Kits
Substances used in medicine
Phenobarbital (IARC Gr 2B)
Antibiotics
Hormones (specify) :
DRH/BCMP/22.10.2015
Anesthetics
Pentobarbital R2 (IARC Gr3)
Halothane (Fluothane) R1B (IARC Gr 3)
Isoflurane (Forane) R1A (IARC Gr3)
Ketamine (IARC Gr 3)
Other anesthetics (specify):
Questionnaire about risks at work
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REMARKS AND COMMENTS:
5/ NANOPARTICULES
Intentional (manufacturing)
Comments:
Intentional (use)
Comments:
Unintentional (pollution, diesel fuel, etc.)
Comments:
DRH/BCMP/22.10.2015
REMARKS AND COMMENTS :
Questionnaire about risks at work
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