QUALITATIVE INDUSTRIAL HYGIENE RISK ASSESSMENT WORKSHEET

Prepared by: Department and Specific Location: Date:

Hazard Description (Chemical ID, Radiation, Noise, etc.):

Is the hazard a:
◊ Gas ◊ Liquid ◊ Particulate (Dust, Fiber, Fume, etc.) ◊ Radiation ◊ Biological ◊ Thermal Extremes ◊ Noise ◊ Other

Is the hazard identified with any notations by OSHA, NIOSH, ACGIH Exposure Limits (PEL, TLV, REL, STEL, Ceiling, etc.)
or Other? If yes describe.

Describe processes or tasks (Description of job, operation, work, location, engr. controls available, PPE, work procedures, admin. controls,
and equipment being used) (If Additional Space is Needed Use Reverse):

How often does the process or task used: Typically how long employee is exposed during a shift?
◊ <15 min ◊ 15 min to 1 hour ◊ ______Hour(s)
◊ Daily ◊ Weekly ◊ Monthly ◊ Biannual ◊ Yearly ◊ ◊ Entire shift (8 Hour, Other______)
Other______ Number of employees doing this job:________

If a chemical, how much used in a shift (ounces, gallons, liters, What type and size of container is it in:
etc)?

Estimated maximum daily quantity on hand:

Characterize how the employee could be exposed (consider skin contact, inhalation, ingestion):

Characterize how the hazard is released by the process (i.e. spraying paint [higher exposure] v. brushing [lower exposure] or scraping lead
based paint [lower exposure] v. abrasive blasting [high exposure]):
Characterize the Environmental Conditions(if applicable):

_________________________________________________________________________________________
◊ Indoor ◊ Outdoor ◊ Confined Space

Ventilation Conditions: ◊ Local Exhaust (Hood, Slot Vent, etc.) ◊ Dilution ◊ General ◊ Ambient Conditions

◊ Room Dimensions: W L H = Room Volume (Use Units)

◊ Air Changes/Hour ___________◊ Capture Distance (potential exposure area) from Ventilation _________

Exhaust Vent Area W______ L_______ Return Vent Area W______ L_______

Cross Sectional Velocity Readings (ft./min.)_____________________________

◊ Temperature ________ ◊ Relative Humidity ____________________________________

Other Conditions based on hazard:

◊ Distance from noise or radiation source to where the exposure occurs ___________________________________________________

General Notes:

Work Area Sketch (or attach diagram, drawing, etc.)

Document previous monitoring results and/or Qualitative (semi-quantitative) Assessment Calculations (as necessary):
Documentation Attached: ◊ Yes ◊ No

CONCLUSIONS (describe results and mitigating aspects):

Interim Engineering/Administrative Controls Recommended (PPE, shielding, ventilation, chemical substitute, etc):

Print/Signature of Preparer: Date:

RECOMMENDATIONS (COMPLETED BY SAFETY/INDUSTRIAL HYGIENIST)

Quantitative Assessment: ◊ Complete – No Further Action Required At This Time ◊ Recommended (Air Sampling/Exposure Monitoring)
Print/Signature of Safety/Industrial Hygienist: Date: