Is formaldehyde or any form of formaldehyde used in your lab?

YES  NO 

If NO, please sign the form and turn it in to OEHS.

If YES, please complete and sign this questionaire.

1) What activities do you perform which utilize formaldehyde?

 
2) Which form/state of formaldehyde is used?

        solid  liquid  gas 

3) Please indicate type(s) of formaldehyde used:

  10% formalin  37% concentrated formaldehyde

  paraformaldehyde  other (specify) 

4) Amount of formaldehyde used can best be described in:

        milliters (ml) liters (l) grams (g)

5) Are formaldehyde activities performed with the use of ventilation control? If NO, go to question 6.

        If yes, please indicate the ventilation control used:
chemical fume hood
counter top unit connected to ventilation system
counter top unit with charcoal filter
other ventilation, please specify 

6) The length necessary to perform the activity is
0-1  1-2  2-3  3-4  4-5  More than 5
    hours per day.

7) What is the frequency of formaldehyde used?

daily
weekly
monthly
yearly

8) Please specifically indicate which day(s) of week formaldehyde usage is heaviest. (For monitoring purposes) 

9) What training have you received with respect to procedures to follow when using formaldehyde, health hazards related to formaldehyde, or personal protective equipment for use with formaldehyde?

 

Has training been documented? YES  NO 

10) Have you/your work area been monitored for airborne levels of formaldehyde? YES  NO 

        If yes, a) When? (date)

                  b) Were you informed of the formaldehyde levels? YES  NO 

                  c) What were the formaldehyde levels? 

11) State the location of the nearest eyewash and safety shower.
 
 

12) Have you received a medical examination from your employer due to a (possible) formaldehyde exposure?        
YES  NO 

13) Have you experienced any spills, leaks, or emergencies with formaldehyde? YES  NO 

        If yes, a) Describe the circumstances.
 
                   b) How often does this occur? 

14) Are all containers of formaldehyde properly labeled? YES  NO 

      Are Material Safety Data Sheets (MSDSs) readily available? YES  NO 

       Have you read and familiarized yourself with the MSDSs? YES  NO 

15) Have you experienced any adverse affects while performing your work? YES  NO 

        If yes, a) Please describe.

                  b) Have you informed your supervisor? YES  NO 
_______________________________________ _________________________________________

Signature:                              Date:

For OEHS use only:

Monitoring Priority
Priority 1 - Immediate
Priority 2 - Delayed
Priority 3 - No monitoring required
________________________________________ _________________________________________

Signature:                             Date: