Silica Dust Safety Form
Complete this form to document silica dust exposure controls, training, and workplace safety precautions.
Employee Name
*
First Name
Last Name
Worksite Location
*
Job Title/Role
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has the employee received silica dust safety training?
*
Yes
No
Has the employee completed fit testing for respiratory protection?
*
Yes
No
What engineering controls are in place to minimize silica dust exposure?
*
Wet methods
Local exhaust ventilation
Enclosures or barriers
None
Other
Is appropriate personal protective equipment (PPE) being used?
*
Yes
No
Not Applicable
List any observed silica dust hazards or unsafe conditions.
Corrective actions taken or recommended
Submit
Should be Empty: