Appendix A. Reproductive Hazard Questionnaire Date Name UCI ID# Dept. Phone E-mail Supervisor Phone E-mail Agents used at work Continue on separate page if needed – List Frequency Physical Quantity Protective Controls Tasks – Materials and State used Equipment used Describe currently Duration (solid, per use, (gloves, (fume how material used or of use liquid, in unit respirator, hood, will be used. expect to (once/day gas) of time etc.) glove box, use during for two (e.g., 10 other local hours. etc. ml per exhaust, wk) radiation period or barrier, job pregnancy rotation, etc.) Ventilation systems available to you. Chemical Agents: Biological Agents (and Biosafety level): Radiation: Questions about chemicals: Do other people in your area use the same chemicals? If yes, how many other people? Are any of chemicals heated? If yes, to what temperature? Which ones?
Appendix A. Reproductive Hazard Questionnaire Date Name UCI ID# Dept. Phone E-mail Supervisor Phone E-mail Agents used at work – Continue on separate page if needed List Materials currently used or expect to use during period or pregnancy Frequency and Duration of use (once/day for two hours. etc. Physical State (solid, liquid, gas) Quantity used per use, in unit of time (e.g., 10 ml per wk) Protective Equipment (gloves, respirator, etc.) Controls used (fume hood, glove box, other local exhaust, radiation barrier, job rotation, etc.) Ventilation systems available to you. Tasks – Describe how material will be used. Chemical Agents: Biological Agents (and Biosafety level): Radiation: Questions about chemicals: Do other people in your area use the same chemicals? If yes, how many other people? Are any of chemicals heated? If yes, to what temperature? Which ones?
Appendix_A-reproductive-questionnaire.docx