Delaware Health and Social Services Division of Public Health Workplace Assessment of Potential for Exposure to Hazardous Materials Bill Leitzinger, Administrator Office of Occupational Health Phone: 302-744-4811 Mobile: 302-584-4631 Fax: 302-739-3071 E-mail: William.Leitzinger@state.de.us The Office of Occupational Health Delaware Health and Social Services Division of Public Health, Health Systems Protection The Division of Public Health has recently established an Office of Occupational Health. The mission of this new office is to act as a resource to employers in their efforts to minimize exposure to hazardous materials in the workplace in order to improve the workplace environment for the benefit of all Delawareans. The Office of Occupational Health provides confidential education and consultation services - at no charge - for public sector employers and employees, including State of Delaware departments and agencies. For All Public Sector Employers, the Office of Occupational Health: > Performs worksite hazard analysis and environmental testing > Makes recommendations for hazard prevention and control > Provides safety and health training and educational materials to promote employee safety in order to minimize their risk of exposure to carcinogenic materials For All Employers and the General Public, the Office of Occupational Health: > Provides workplace safety & environmental hazard-reduction information and methodologies for all employers, employees, and the general public. > Oversees both the Delaware Healthy Homes website as well as the new Occupational Health web pages that reside on the State of Delaware website. These web pages are important communication tools for both employers, employees, and the general public. > Coordinates the Healthy Homes/Healthy Workplace multi-media campaign designed to educate all Delaware employers and the general public about possible exposures to cancer causing substances in their indoor environment and ways to reduce their risk. > Manages a multi-media campaign designed to raise public awareness of Delaware’s “Worker Right-to-Know” law, which states that all Delaware employers need to provide their employees with access to information regarding hazardous chemicals they may be exposed to at work. Bill Leitzinger, Administrator Office of Occupational Health Phone: 302-744-4811 Mobile: 302-584-4631 Fax: 302-739-3071 E-mail: William.Leitzinger@state.de.us Doc. No. 35-05-20/08/04/01 Workplace Assessment of Potential for Exposure to Hazardous Materials FACILITY INFORMATION SHEET Survey Date: ________/________/________ Surveyor ID: ____________________________________________ Facility ID: ____________________________________________ NAICS/SIC Codes: _______________ Size: Small / Medium / Large Status: Private / Public Facility Information Facility Name: ___________________________________________________________________________ Address: ___________________________________________________________________________ City: _________________________ Zip: ____________ County: ___________________ Contact: ____________________________ Phone: _________________ Email:__________________ Doc. No. 35-05-20/08/04/01 Part I – Management Interview A. General Facility Information A1. What is your major activity? Comment A2. What are your chief products, services, lines of trades, etc? Comment A3. Approximately how many years has this facility been involved in this activity Years A4. How many shifts do you have at the present time? Shifts A5. How many hours per shift Hours A6. How many employees are in the work areas (production areas) as opposed to the administrative or other similar areas? Employees A6a. Does the work environment appear to be overcrowded for its intended use? Yes No Comment A7. Is the facility certified under industry or federal standard (i.e. VPP, ISO) Yes No Comment A7a. If so, Which ones? Comment A8. Is there a designated lunch room/area Yes No Comment B. Industrial Hygiene and Safety Practices B1. Do you provide the following medical surveillance on a periodic basis to those individuals who may be in contact with hazardous substances? Yes No Comment B2. Do you employ a full or part time individual(s) responsible for the prevention of occupational injuries or illness (Site Safety Officer)? Yes No Comment B3. Do you have a written Health & Safety Plan in place? Yes No Comment B4. Is radioactive material stored on site? Yes No Comment B5. Is radioactive material used on site? Yes No Comment B6. Is the use of X-rays a part of your service or production? Yes No Comment B7. Has your facility received industrial hygiene/safety consulting services? Yes No Comment B7a. If so, How often? Daily Weekly Monthly B8. Do you have a program under which you regularly or periodically monitor for the presence of fumes, gases, mists, dusts, or vapors? Yes No Comment B9. Has any monitoring/testing exceeded any federal, state, or local regulations or recommendations? Yes No Comment B10. Does this facility re-circulate exhaust air from any process or plant area? Yes No Comment B11. Are there areas in this facility in which personal protection devices or equipment are required or recommended? Yes No Comment B12. Has someone been designated to see to it that personal protective devices and equipment are serviced and maintained? Yes No Comment B13. Do you have a program under which you regularly or periodically conduct safety inspections of this facility? Yes No Comment B14. Do you have a regularly scheduled formal safety training program for your employees? Yes No Comment B15. May I see the latest summary of Occupational Injuries and Illness Form (OSHA Form 300)? Yes No Comment B15a. Occupational Injuries Number of deaths Cases Number of injuries with lost workday Cases Number of injuries without lost workdays Cases B15b. Occupational Illness Skin diseases or disorders Cases Dust diseases of the lungs Cases Respiratory conditions due to toxic agents Cases Poisoning (systemic effects of toxic materials) Cases Disorders due to physical Agents Cases Disorders associated with repeated trauma Cases Deaths Cases Number of illness with lost workdays cases Number of illness without lost workdays Cases Doc. No. 35-05-20/08/04/01 Comment Table Question # Comment Doc. No. 35-05-20/08/04/01 Part II – Facility Walk-Through The purpose of Part II of the Workplace Assessment is to record potential exposures observed by the surveyor. The occupational titles, duration of exposure, engineering and administrative controls and personal protective equipment used are recorded. In addition, the purpose of the walk-through is to identify and record any potential exposures to specific hazardous substances and/or carcinogens known to be used in the specific industry being surveyed. Part II – Facility Walk-Through A. General Facility Information A1. Are there hazardous substances used on site? If yes, List in Toxic Substance Inventory Sheet Yes No A2. Do you store hazardous substances on site? If yes, List in Toxic Substance Inventory Sheet Yes No A2a. How much is used on an annual basis? A3. How many employees are in contact with these hazardous substances? Employees A4. Typical duration of contact/exposure during the work day (hours)? Hours A5. Typical number of days of the week exposed to hazardous chemicals? Days A6. Are visible emissions present during the production process? Yes No Comment A7. Is an indirect observed exposure to a hazardous substance present? Yes No Comment A8. Ventilation controls in operations (local exhaust, fume hoods, etc)? Yes No Comment A8a. Is Personal Protective Equipment used by Employees? Yes No Comment A8b. Respirators? Yes No Comment A8c. Gloves? Yes No Comment A9. Overalls/Suits? Yes No Comment A9a. Are Proper OSHA sign/labels present throughout the facility? Yes No Comment A10. Are hazard signs offered in an alternate language (ie. Spanish) Yes No Comment A11. Proper storage of wastes/materials? Yes No Comment A12. Is there a visible presence of mold growth within the facility? Yes No Comment B. Office Environments B1. Does proper HVAC ventilation appear to be present? Yes No Comment B2. Are photocopiers/printers near employee desks/offices? Yes No Comment B3. Do employees routinely complain of odors, dizziness, headaches, etc? Yes No Comment B4. Is the office cleaned on a regular basis by company employees? Yes No Comment B5. Is the office cleaned on a regular basis by an outside contractor? Yes No Comment C. Medical Environments C1. Are general anesthesia (gas) used? List type in table. Yes No Comment C2. Are biological hazards present (i.e. blood, human wastes)? Yes No Comment C2a. If biological hazards are present, are they properly stored, labeled, disposed? Yes No Comment C3. How frequently are areas/rooms cleaned or disinfected? List in Table. Daily Weekly Comment C4. Is glutaraldehyde used for sterilization? Yes No Comment C5. Are there significant odors present following cleanings? Yes No Comment C6. Is personal hygiene being practiced? Yes No Comment D. Construction/Utility Environments D1. Is compressed gas used? If so, what type? List in Table. Yes No Comment D2. Are asbestos-containing materials ever handled? Yes No Comment D3. Exposure to potential Lead-Based Paint? Yes No Comment D4. Is there an exposure to PCBs (ie. Light Ballast, electrical Transformers)? Yes No Comment D5. Is there an exposure to heavy metal, besides lead (As, Ba, Cd, Cr, Hg, Se, Ag)? Yes No Comment D6. Are diesel generators used? Yes No Comment D7. Is (airborne/surface) dust visibly present during normal operations? Yes No Comment D8. Is there an active use of spray applicants? Yes No Comment D9. Are you aware of the new OSHA standard for Chromium and is it being followed? Yes No Comment D10. Is personal hygiene being practiced? Yes No Comment E. Agricultural Environments E1. Are pesticides applied/stored properly? Yes No Comment E2. Dust hazards from feed, soil, livestock, etc? Yes No Comment E3. Biological hazards from feces, feathers, livestock, etc? Yes No Comment E4. Is there an active use of spray applicants? Yes No Comment E5. Is personal hygiene being practiced? Yes No Comment Doc. No. 35-05-20/08/04/01 WORKPLACE ASSESSMENT PART IV – QA/QC DOCUMENTATION Survey Date: _________/_________/__________ Surveyor ID: ______________________________ Facility ID: ______________________________ NAICS/SIC Codes: _______________ 1. Disposition of Survey a. Completed b. Partially Completed c. Refused to be Surveyed 2. Did management personnel prohibit you from surveying any areas of the facility? a. Yes b. No 3. Were you accompanied by someone from the facility when you performed Part II of the survey? a. Yes b. No 4. What questions of the survey were not answered? a. b. c. d. e. f. g. 5. Was a brief exit interview performed with the point of contact at the facility? a. Yes b. No Inspector _______________________________________________ Project Manager _________________________________________ WORKPLACE ASSESSMENT Doc. No. 35-05-20/08/04/01 PART III – SOC CODE CHECKLIST SOC CODE PRESENT EXPOSURE SUBSTANCE (s) (YES/NO) (INFERRED/OBSERVED) LIST CHEMICAL(s) 11-0000 Management Occupations 13-0000 Business and Financial Operations Occupations 15-0000 Computer and Mathematical Occupations 17-0000 Architecture and Engineering Occupations 19-0000 Life, Physical, and Social Science Occupations 21-0000 Community and Social Services Occupations 23-0000 Legal Occupations 25-0000 Education, Training, and Library Occupations 27-0000 Arts, Design, Entertainment, Sports, and Media Occupations 29-0000 Healthcare Practitioners and Technical Occupations 31-0000 Healthcare Support Occupations 33-0000 Protective Service Occupations 35-0000 Food Preparation and Serving Related Occupations 37-0000 Building and Grounds Cleaning and Maintenance Occupations 39-0000 Personal Care and Service Occupations 41-0000 Sales and Related Occupations 43-0000 Office and Administrative Support Occupations 45-0000 Farming, Fishing, and Forestry Occupations 47-0000 Construction and Extraction Occupations 49-0000 Installation, Maintenance, and Repair Occupations 51-0000 Production Occupations 53-0000 Transportation and Material Moving Occupations 55-0000 Military Specific Occupations 11-0000 Management Occupations 13-0000 Business and Financial Operations Occupations 15-0000 Computer and Mathematical Occupations 17-0000 Architecture and Engineering Occupations 19-0000 Life, Physical, and Social Science Occupations 21-0000 Community and Social Services Occupations 23-0000 Legal Occupations Doc. No. 35-05-20/08/04/01 Toxic Substance Inventory Table Facility ID: ____________________________ Facility Name: _____________________________________________________________________________ Address: ________________________________________________ City: ________________ Zip: ___________________ County: _____________________ Site Contact: Phone: Fax: Email: Daily Observed Inferred PPE Used 1 Part Time Weekly MSDS Known Potential Potential during Full Time (>30 minutes, Monthly Onsite (O) Chemical Name Trade Name CAS# Quantity Carcinogen Exposure Exposure exposure (>4 hours) <4 hours) Yearly Enclosed (E) 1. Paper filter (PF), Powered Air purifying Respirator (PAPR), Half-faced (HF – HEPA(H), Organic O), Supplied Air (SA), None (N)