Appendix J: Employee Overexposure Information

The following information should be provided to the examining physician.
 

Employee Name:

Date of Incident:

Department:

Chair:

Identity of the hazardous chemical(s) to which the employee may have been exposed:

Duration of exposure:
 
 

Amount of chemical(s) involved:
 
 

Description of the incident:
 
 
 
 
 
 

Control measures used at time of incident (fume hood, personal protective equipment etc.)
 
 

Location of injuries or sites of contact, e.g. eyes, skin:
 
 

Signs and/or symptoms, if any:
 
 

Are signs and symptoms same as indicated on MSDS?
 
 

Witnesses (include telephone numbers):
 

____________________________ 

Signature

________________

Date