Can you smell or taste any chemical fumes or vapors where you work? If yes, which ones? Do you feel sick when you work with any of the chemicals, and feel better at other times? Do any of the chemicals you work with get on your skin? If yes, which ones? Do you have any specific health or safety concerns about your work? If so, describe: Do you work in the vivarium with live animals or animal tissues? Yes No if yes, have you updated your LAOHP Form online? Yes No Do you store or consume food or beverages in your workplace? Yes No What type of personal protective equipment do you wear while working? Eye/Face Protection Foot Protection Head Protection Safety glasses with side shields Safety boots Hard hat Laser safety glasses Toe caps Hearing protection – Safety goggles Metatarsal guards earplugs, earmuffs Face shield Rubber boots Welder’s helmet/ face shield Body Protection Hand Protection/Gloves Fall restraint/fall protection Leather Rubber apron Natural rubber Disposable Tyvek lab coat/coveralls Cotton (coated/not coated) Lab coat or coveralls Nitrile Welding leather sleeve guards Heat resistant Nomex Coveralls Neoprene Other: Chemical resistant Butyl rubber Latex Other (PVC, PVA, Viton) Cryogenic Anti-vibration Cut resistant (e.g., Kevlar) Other: Respirator Protection APR Chemical Cartridge/Filter Types: Filtering Face respirator (N, P or R) Multi-gas/OV Air purifying respirator AG/Acid Gas Supplied air line OV/Organic Vapor Half face OV/AG P-100
Can you smell or taste any chemical fumes or vapors where you work? If yes, which ones? Do you feel sick when you work with any of the chemicals, and feel better at other times? Do any of the chemicals you work with get on your skin? If yes, which ones? Do you have any specific health or safety concerns about your work? If so, describe: Do you work in the vivarium with live animals or animal tissues? Yes No if yes, have you updated your LAOHP Form online? Yes No Do you store or consume food or beverages in your workplace? Yes No What type of personal protective equipment do you wear while working? Eye/Face Protection Foot Protection Head Protection Safety glasses with side shields Laser safety glasses Safety goggles Face shield Welder’s helmet/ face shield Safety boots Toe caps Metatarsal guards Rubber boots Hard hat Hearing protection – earplugs, earmuffs Body Protection Hand Protection/Gloves Fall restraint/fall protection Rubber apron Disposable Tyvek lab coat/coveralls Lab coat or coveralls Welding leather sleeve guards Nomex Coveralls Other: Leather Natural rubber Cotton (coated/not coated) Nitrile Heat resistant Neoprene Chemical resistant Butyl rubber Latex Other (PVC, PVA, Viton) Cryogenic Anti-vibration Cut resistant (e.g., Kevlar) Other: Respirator Protection Filtering Face respirator (N, P or R) Air purifying respirator Supplied air line Half face APR Chemical Cartridge/Filter Types: Multi-gas/OV AG/Acid Gas OV/Organic Vapor OV/AG P-100
Appendix_A-reproductive-questionnaire.docx