110

ERHMS
NIOSH Health Hazard Evaluation Program Worker Observation Form (Exposure Assessment
Data Collection Template)
GENERAL NFORMATON
Name: Job title:
Process description: Length of process:
Dept: Line: Location:
Specifc tasks:
Potential exposures:
Sampling conducted: Air Noise Heat stress Dermal/surface Other:
W
O
R
K
E
R


O
B
S
E
R
V
A
T
I
O
N


F
O
R
M
HETA #
Date:
Sequence #
P
a
g
e

1


(
S
e
e

B
a
c
k
)
RESPRATORY PROTECTON
Type (half-mask, etc.): Mnf: Model:
Type of cartridge or flter:
Respirator use:
Mandatory Voluntary
Is employee in a written respiratory protection program?
Yes No Dont know
Correct type of respirator for
exposures?
Yes No Worn correctly? Yes No
Respirator condition
(valves, seal, cleanliness, etc.):
Frequency of use: Changeout frequency
(for respirator or cartridge):
Employees judgment of
effectiveness:

Company name:
Completed by:
Air SAmpling informAtion
(Draw arrows to link samples for TWA calculation. Gray is required)
Sample #
Sampling media
Pump #
Type PBZ Area PBZ Area PBZ Area PBZ Area
Agent(s)
Task (if task
based)
Start time
(military)
Stop time
(military)
Pump time (min)
Avg. fow (LPM)
Conc.
Averaging time
(8hr, 15min, etc.)
111
ERHMS
NIOSH Health Hazard Evaluation Program Worker Observation Form (Exposure Assessment
Data Collection Template)
protective clothing / gloveS
Type (gloves,
coveralls, etc)
Mnf
Model
Material
Available but not
worn

Changeout freq.
Condition Good Fair Poor Good Fair Poor Good Fair Poor
Description
Other PPE Glasses Hard hat Steel Toe Boots Other:

Uncovered skin
(Check all that
apply)
Arms Hands Wrist Neck
Face Legs Other:

notes



P
a
g
e

2
W
O
R
K
E
R


O
B
S
E
R
V
A
T
I
O
N


F
O
R
M
enGIneerInG controls
Task/Process
Type (LEV,
enclosure,
etc)
Mnf
Model
Description
Judgment of
effectiveness
Effective Ineffective Effective Ineffective Effective Ineffective
If ineffective,
why?
Further
evaluation
needed?
Yes No Yes No Yes No
HearInG protectIon
Type: Plugs Muffs Both Available but not worn
Mnf: Model: NRR:
Use: Mandatory Voluntary Worn correctly? Yes No
Is employee in a written hearing conservation program? Yes No Dont know