Employee/Area #1

  • Name of Employee/Area

  • Employee Monitoring Photo

  • Employee Working Photo

  • Job Title

  • Pump Model

  • Instrument ID

  • Instrument ID

  • Instrument ID

  • Instrument ID

  • Collection Media

  • Sampling Media

  • Analysis Method

  • Analysis Method

  • Start Time

  • End Time

  • Elapsed Time (Minutes)

  • Was the employee wearing respiratory protection?

  • Respiratory Protection

  • Respirator Make/Model

  • Cartridge Information

  • Respiratory Protection

  • Was the employee wearing additional PPE?

  • Eye Protection

  • Type of Eye Protection

  • Shade Number

  • Gloves

  • Type of Glove

  • Steel-Toe Shoes

  • Face Protection

  • Face Protection Type

  • Shade Number

  • Was there adequate ventilation?

  • Type of ventilation

  • Description

  • Tasks Worked/Completed in Area

  • Break Times

  • Additional Comments

  • Additional Photos

  • Were the pumps pre-calibrated?

  • Date

  • Flow (LPM)

  • Were the pumps post-calibrated?

  • Date

  • Flow (LPM)

  • Calibration by

  • Average Flow Rate (LPM)

  • Sample Volume (L)

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