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Date:
__________________________
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Employer Name:
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Work Area:
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Employer Address:
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To whom it may concern:
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To
evaluate potential chemical exposures, I am requesting the
following information under the OSHA Standard: 29CFR 1910.1020 and
1910.1200. (I understand that OSHA 11C prohibits employee
harassment). I understand this regulation applies to employees and
former employees.
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A list of all chemicals, including pesticides, used
in this employee’s work area during the following period
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period of time.
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Material safety data sheets on all chemicals (or
mixtures) and pesticides used in this employee’s area
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during the following period of time.
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Please
contact the manufacturer to obtain written confirmation that the
Safety Data Sheets contain complete medical information on all
health effects reported in the medical literature.
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Monitoring results of chemical exposure levels in
this work area or similar area including your copy of
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measurements done in-house, by contract, or by your
insurer, anytime before the following period of time:
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A description
of your Hazard Communication (Right to Know) Training Program.
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Measurements
to evaluate local exhaust ventilation for this work area.
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Measurements
of noise levels in this area.
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Medical
monitoring information done by or for you on this employee,
including:
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Any study of problems or hazards including this
work area.
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The schedule or records documenting pesticide
applications in the patient’s/employee’s building.
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Other:
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Employee/Patient
Authorization
Signature:
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Date
of Birth:
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Employee/Patient
Name
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Social
Security #:
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Employee/Patient
Address:
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Please
send the information
to____________________________________________________________
WITHIN 15 DAYS as specified by OSHA. If any of the above
information involves trade secret data, please indicate which
information (e.g., chemical identity, formulation) is trade secret
and this will be maintained strictly confidential. Please send
trade secret information to my doctor as required by OSHA with
assurance that although my doctor cannot tell me the chemical(s),
“trade secret” that I can be fully informed about health
effects by the manufacturers Safety Data Sheets.
Thank you.
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