Step 1 of 3 33% The purpose for completing this form is to: Determine if employees/staff need to be in NCSU’s Respiratory Exposure Program and/or if monitoring is needed, Comply with OSHA’s Respiratory Exposure Standard. Please complete this form to determine if the employee must be included in the University Respiratory Exposure Program. A copy of the information you submitted will be sent to you. Please maintain it in your personnel or safety plan records.Name* First Last Employee/Student ID Number*Enter your 9 digit employee/student ID number.Email* PhoneDate MM slash DD slash YYYY Supervisor / Principal Investigator Information* First Last Phone # Email Position / Job*Employment Type*FacultyStaffStudentDivision*Academic Outreach & EntrepreneurshipAthleticsBudget & Resource ManagementCALS - College of Agricultural & Life SciencesCampus EnterprisesChancellor's officeCHASS - College of Humanities & Social SciencesCNR - College of Natural ResourcesCOD - College of DesignCOEd - College of EducationCOE - College of EngineeringCOS - College of SciencesWCOT - Wilson College of TextilesCVM - College of Veterinary MedicineDASADELTAEHPSEMAS - Enrollment ManagementExtension & EngagementFacilitiesFinance DivisionLibrariesOIT - Office of Information TechnologyORIEDPoole College of ManagementSocial/Clinical ResearchOtherDivision / OtherDepartment / Unit* The purpose of this evaluation is to characterize the respiratory hazards associated with the use or handling of hazardous chemicals and materials in your work task(s). In order to initially evaluate the respiratory exposure hazards, please answer the following:What are the potentially hazardous chemicals(s) or substance(s) which have prompted the request for respiratory protection or an evaluation?*Describe in detail the processes or operations in which the chemical or material is or will be used. Include information about the chemical and physical state(s) of substances used, the amount of each chemical used, and the physical conditions under which the chemicals are used (e.g. temperature, pressure).*How often is the process performed?*Describe any other factors which you think may increase hazards from working with the chemical or material such as grinding, machining, evaporation, etc.Describe the work environment and working conditions:Approximate dimensions of work areaAny general or local exhaust in the area* Yes No Please describeIs the work space in an unusual configuration (i.e confined or enclosed space)?* No Confined Space Enclosed Space Other (describe below) Describe Are any other staff or students involved in or in close proximity to the process?* Yes No Please list those involvedFirstLast Any other conditions that you consider important:Describe the level of work activity and any possible physical stresses on the respirator user.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.