Silica Exposure Control Form
Document workplace silica exposure controls and worker assignment details accurately for compliance and safety.
Worker Full Name
*
First Name
Last Name
Job or Task Description
*
Date of Assignment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Work Location
*
Silica Exposure Source
*
Please Select
Cutting concrete
Grinding masonry
Demolition
Sandblasting
Other
Engineering Controls Used
*
Water suppression
Local exhaust ventilation
Enclosures
None
Other
Administrative Controls Used
Task rotation
Restricted access
Work scheduling
Other
Personal Protective Equipment (PPE) Used
*
N95 respirator
Half-face respirator
Full-face respirator
Protective clothing
Other
Exposure Monitoring Conducted?
*
Yes
No
Supervisor Review/Comments
Submit
Should be Empty: