Employee Exposure Monitoring Form

Part 1
Employee Name
 
 
  		Name of person conducting
monitoring: 		Date of monitoring:
Site of activity monitored:
 
 
 Description of activity involving exposure:
Exposure agent monitored:
  		Indicate: q Personal Sample q Area Sample
(Check one)
Name of person monitored:
 
 
  		Social Security Number of person monitored:
Assumed exposure level during activity monitored:
 
  		Pump calibration date:
Types of personal protective devices/equipment worn during monitor:
 
 
 
 
Pump flow rate: Total volume of air sampled:
Part 2
Name and address of analytical laboratory:
 
 
Duration of monitoring:  
 
 
 
  		Sample result: Date of analysis:
Sample and analytic method used:  
 
 
 
Directions: Prepare a form for each personal sample taken. Fill out Part 1 of the form at the time of monitoring. Fill out Part 2 of the form after analytical results are received. Make a copy of the form. Send the original to EH&S. Keep the copy at the worksite until the project is completed. After the project is completed, give the copy to the employee monitored, (or make a second copy to be given to the employee if the first copy is to be kept with project records).