Oklahoma State University Employee Exposure Report
| Last name:______________________ | First Name:________________________ | Middle Initial:_____ |
| Department:______________________ | Title:_________________________ | SSN: ______________ |
| Date/Time of Exposure:_____________________________________________________________ |
| Duration of Exposure:______________________________________________________________ |
| Location of Exposure (Bldg. & Rm #):_________________________________________________ |
| Chemical / Hazardous Substance Name(s):______________________________________________ |
| Chemical Abstract Number(s) - (CAS):_________________________________________________ |
| Trade and/or common name(s) of chemical(s) or hazardous substance(s):______________________ |
| ________________________________________________________________________________ |
| Type of exposure (e.g. inhalation, ingestion, contact) (If contact, what body part was involved?) |
| ________________________________________________________________________________ |
| How did exposure occur? (Use additional sheet if necessary):________________________________ |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| Was personal protective equipment available? | Yes____ No____ |
| Was personal protective equipment used? | Yes____ No____ |
| If personal protective equipment was used, what type(s)?___________________________________ |
| Did employee receive training/instructions prior to exposure? (Explain)________________________ |
| ________________________________________________________________________________ |
| Were any symptoms present at time of exposure? | Yes____ No____ |
| If so, describe (attach physician's report, if applicable):_____________________________________ |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| Severity of exposure: | First Aid____ | Medical Treatment____ | Unknown____ |
| Describe:_________________________________________________________________________ |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| Did employee lose time from work? | Yes____ No____ |
| Estimate of lost time:______________________________________________________________ |
| Were other employees exposed? | Yes____ No____ |
| If so, list names & SSN (use additional sheet if necessary):_________________________________ |
| ________________________________________________________________________________ |
| List suggestions to prevent reoccurance:________________________________________________ |
| ________________________________________________________________________________ |
________________________________________________ |
________________________________________________ |