Chemical Exposure Assessment
Please complete this form to document and assess any incident or risk of chemical exposure.
Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Date and Time of Exposure
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Exposure (e.g., lab, warehouse, outdoors)
*
Type of Chemical Involved
*
Please Select
Acid
Base/Alkali
Solvent
Pesticide
Gas/Vapor
Other (please specify)
Route of Exposure (select all that apply)
*
Inhalation
Skin Contact
Eye Contact
Ingestion
Injection
Other
Duration of Exposure (in minutes)
*
Please rate the severity of your symptoms (if any)
*
No symptoms
0
1
2
3
4
5
6
7
8
9
Severe symptoms
10
0 is No symptoms, 10 is Severe symptoms
Symptoms Experienced (select all that apply)
*
No symptoms
Eye irritation
Skin irritation/rash
Coughing
Difficulty breathing
Nausea/vomiting
Headache
Dizziness
Other
Personal Protective Equipment (PPE) Used
*
Gloves
Goggles/Face Shield
Lab Coat/Apron
Respirator/Mask
None
Other
Exposure Risk Assessment
*
Rows
Likelihood (1=Rare, 5=Almost Certain)
Consequence (1=Insignificant, 5=Severe)
Before Controls
1
2
After Controls
3
4
Actions Taken Following Exposure (e.g., washed area, notified supervisor, sought medical attention)
*
Additional Comments or Details
Submit Assessment
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