Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Untitled Page
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Employee Name and Number
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Work Area or Equipment Number
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Are you able to get to the employee for the sample check?
- Yes, full interaction
- Yes, in-field observation with no interaction
- No, interaction was attempted
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LAVG
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Is this normal routine shiftwork?
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What type of work is being done?
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What PPE is being worn?
- Hard Hat
- Safety Glasses
- Hi-Vis
- Ear Plugs
- Ear Muffs
- Half-Face Respirator
- Full-Face Respirator
- PAPR
- Steel/Composite Toe Boots
- Gloves
- Heat Suit
- Welding PPE
- Chemical Suits (Tyvex, Red suits, etc.)
- None
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Is the employee Fit for Duty for their respirator if they use one?
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If they are wearing a respirator, can they perform a negative and positive fit check?
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Is the employee wearing their ear plugs, or other hearing protection, the right way?
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Picture of Sample
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Picture of Work Area and/or Equipment Cab
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Has the employee been filling out their Task Sheet?
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If the employee is in a closed cab, how are the cab seals? Are there any air leaks in the cab? etc
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If the employee is in a cab, is their cab clean?
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If the employee is in a cab, are the windows up and doors closed?
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Discuss best practice for noise and dust control with employee
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Does the AC/heat work inside the cab?
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What are the ventilation/weather conditions?
- Hot
- Humid
- Water truck recently watered roads
- Cold
- Snowing
- Raining
- Dusty
- Dry
- Roads have not been watered
- Muddy
- Windy
- Poor Ventilation
- Adequate Ventilation
- Ventilation off
- Ventilation on
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Where are the dust, noise, and/or gas exposures coming from?
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What tools/equipment are being used by or near the employee?
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Important Comments
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Where did you see the employee? Was the employee in a cab, outside of a cab, where in the field, etc?
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Was the sampling equipment on the employee?
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Is PPE being worn?
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What are the weather/ventilation conditions?
- Hot
- Humid
- Water truck recently watered roads
- Cold
- Snowing
- Raining
- Dusty
- Dry
- Roads have not been watered
- Muddy
- Windy
- Poor Ventilation
- Adequate Ventilation
- Ventilation off
- Ventilation on
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Important Comments
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What prevented employee interaction?
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Is there another way to check on the employee? Can you see if a shifter/supervisor is able to check that they are wearing their sampling equipment? Or a radio call/check?
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Who was able to check on the sample?
