Worksite History: Please check (√) If You Have Ever Worked In or Around the Following Activities: Chemical Hazardous Waste Industry Pottery or Ceramics Mill Chemistry Laboratory Hospital or Health Care Refinery Coke Oven Lumber Mill Rubber Processing Plant Construction or Demolition Metal Production Sand Pit or Quarry Cotton, Flax, or Hemp Mill Mine (underground or open Sand Blasting pit) Electronics Plant Service Station Nuclear Industry Farm or Agricultural Shipyard or Boat-Building Paper Mill Flour or grain dust operation Smelter Pharmaceutical Foundry industry Plastic Production Chemical Exposure History: Please check (√) If You are now exposed to or have ever worked with: Acids or Caustics Extreme Heat or Cold Plastics Alcohols or glycols Fiberglass Radioactive Materials Arsenic Formaldehyde or Glutaraldehyde Roofing Materials Artificial Butter or other Flavors Fumigants (including vikane) Rubber Cadmium Glycol ethers Silica, Sand, or Rock Dust Carbon Disulfide Heptachlor Solvents/Degreasers Carbon Tetrachloride Hexachlorobenzene Soots or Tars Chlorine or Hypochlorite Isocyanates (TDI, MDI) Spray Painting Chloroform Lead Styrene or Urethane Chromates Loud or Continuos Noise Talc Chromic Acid Mist Mercurey Toluene Cutting Oils Methylene Chloride Tri/ Perchloroethylene DDT Microwaves, Lasers Two-Part Glues or Sealants Dioxin Nickel Vehicle or Diesel exhaust Dust Coal Paint or varnish Vinyl Chloride Dust Sandblasting PCB’s Welding fume or gas Dust Other Perfumes Xylene Epoxy Resin Pesticides or Herbicides Ethylene Dibromide Petroleum Ethylene Oxide Phenol Explosives or Blasting Phosgene Is there something you were exposed to that you are concerned about that is not listed here? Yes___ No ___ Please provide details for all checked boxes:
Worksite History: Please check (√) If You Have Ever Worked In or Around the Following Activities: Chemical Chemistry Laboratory Coke Oven Construction or Demolition Cotton, Flax, or Hemp Mill Electronics Plant Farm or Agricultural Flour or grain dust operation Foundry Hazardous Waste Industry Hospital or Health Care Lumber Mill Metal Production Mine (underground or open pit) Nuclear Industry Paper Mill Pharmaceutical Plastic Production Pottery or Ceramics Mill Refinery Rubber Processing Plant Sand Pit or Quarry Sand Blasting Service Station Shipyard or Boat-Building Smelter industry Chemical Exposure History: Please check (√) If You are now exposed to or have ever worked with: Acids or Caustics Alcohols or glycols Arsenic Artificial Butter or other Flavors Cadmium Carbon Disulfide Carbon Tetrachloride Chlorine or Hypochlorite Chloroform Chromates Chromic Acid Mist Cutting Oils DDT Dioxin Dust Coal Dust Sandblasting Dust Other Epoxy Resin Ethylene Dibromide Ethylene Oxide Explosives or Blasting Extreme Heat or Cold Fiberglass Formaldehyde or Glutaraldehyde Fumigants (including vikane) Glycol ethers Heptachlor Hexachlorobenzene Isocyanates (TDI, MDI) Lead Loud or Continuos Noise Mercurey Methylene Chloride Microwaves, Lasers Nickel Paint or varnish PCB’s Perfumes Pesticides or Herbicides Petroleum Phenol Phosgene Plastics Radioactive Materials Roofing Materials Rubber Silica, Sand, or Rock Dust Solvents/Degreasers Soots or Tars Spray Painting Styrene or Urethane Talc Toluene Tri/ Perchloroethylene Two-Part Glues or Sealants Vehicle or Diesel exhaust Vinyl Chloride Welding fume or gas Xylene Is there something you were exposed to that you are concerned about that is not listed here? Yes___ No ___ Please provide details for all checked boxes: