Chemical Exposure Assessment

Chemical Exposure Assessment
Please complete this form to document and assess any incident or risk of chemical exposure.
Full Name
First NameLast Name
Contact Email Address
example@example.com
Date and Time of Exposure
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Location of Exposure (e.g., lab, warehouse, outdoors)
Type of Chemical Involved
Route of Exposure (select all that apply)
Other
Duration of Exposure (in minutes)
Please rate the severity of your symptoms (if any)

0
1
2
3
4
5
6
7
8
9
10
0 is No symptoms, 10 is Severe symptoms
Symptoms Experienced (select all that apply)
Other
Personal Protective Equipment (PPE) Used
Other
Exposure Risk Assessment
Rows Likelihood (1=Rare, 5=Almost Certain) Consequence (1=Insignificant, 5=Severe)
Before Controls
After Controls
Actions Taken Following Exposure (e.g., washed area, notified supervisor, sought medical attention)
Additional Comments or Details
Should be Empty:

Select theme:

Rows	Likelihood (1=Rare, 5=Almost Certain)	Consequence (1=Insignificant, 5=Severe)
Before Controls
After Controls