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Safety & Compliance Assistance Program
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Reproductive and Developmental
Health Hazard Questionnaire

IMPORTANT: When you submit this completed form, your responses will be sent via email only to the name you selected from the list of recipients. For privacy reasons, your responses will not be displayed on your screen.

For an even more secure means of submitting your completed questionnaire, please fill out the PDF version instead, print it, and then either fax or ID mail it. Please refer to the PDF version for additional information.

If you have any questions, please contact EH&S at 723-0448.

* = required fields
Contact information:
* Name:
Date:
* Phone:
* E-mail:
Dept.:
Supervisor:

4 A. Agents used at work (click to expand / collapse)
List materials you are currently using or anticipate that you might use during preconception period or pregnancy
1) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
2) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
3) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
4) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
5) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
6) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
7) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
8) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
9) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
10) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
11) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
12) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
13) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
14) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:
 
15) Agent Name: Agent Type:
Frequency and Duration of use (e.g. once per day for 2 hrs)
per
for how long:
Physical State of Agent:
Quantity used per unit of time (e.g. 10 ml per week)
per
Protective Equipment
Location

If "Other", please describe:

B. Do you have any specific health or safety concerns about your work? If so, describe:

C. Do you store or consume food or beverages in your workplace?
Yes
No

D. What type of personal protective equipment do you wear while working?
Gloves Respirator
Lab Coat / Apron Hearing Protection
Dust Mask Other (list):
Eye / Face Protection

E. Have you had any spills or unintentional exposures recently? If so, describe:

F. Laboratory Environment: (if applicable)
(1) How much of your time do you spend doing:
Bench work %
Office work %
(2) Are other people working in the same lab room as you?
Yes No

(3) Does your hood have enough room in it?
Yes No
(4) Describe how chemicals are stored in your lab:

G. Describe the physical demands of your work:
 
Duration & Frequency
Description
Lifting:
Bending / Twisting:
Sitting:
Standing:

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