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Substances
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Exposure
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Controls
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Health & Emergency
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Basic Information
Assessment Title
*
Department
Description
Location
*
Work Area
Activity Description
*
Assessment Date
*
Next Review Date
*
Hazardous Substances
Add Substance
Add all hazardous substances used in this activity. Include chemical name, supplier, and GHS hazard information from the Safety Data Sheet (SDS).
Exposure Assessment
For each substance, assess how workers may be exposed, the frequency and duration of exposure, and who is at risk.
Control Measures
Hierarchy of Controls:
Apply controls in order of effectiveness:
Elimination
- Remove the hazard entirely
Substitution
- Replace with less hazardous alternative
Engineering
- Isolate people from hazard (LEV, enclosure)
Administrative
- Change work procedures, training
PPE
- Personal protective equipment (last resort)
Health Surveillance
Health surveillance is required
Reason for Surveillance
Surveillance Types
Frequency
Responsible Person
Occupational Health Provider
Next Surveillance Date
Emergency Procedures
First Aid Measures
Inhalation
Skin Contact
Spill Procedure (Small)
Spill Procedure (Large)
Spill Kit Location
Emergency Contact
Review & Submit
Please review all information before saving. You can save as a draft and submit for approval later.
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Add Substance
Substance Name
*
Product Name
Supplier
CAS Number
Physical Form
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SDS Reference
SDS Date
Signal Word
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Danger
Warning
No Signal Word
Hazard Statements (H-codes)
Hold Ctrl/Cmd to select multiple
Quantity Used
Quantity Stored
