Home | Environmental Controls | Preventing Chemical Injury | Media and Video | SEARCH
Medical Care
| Hazardous Substances | Chemical Updates | "Corporate Crime" | Biography of Dr. Ziem

Click here to download this form to your computer.






Date: __________________________



Employer Name:


Work Area:



Employer Address:





To whom it may concern:




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.




A list of all chemicals, including pesticides, used in this employee’s work area during the following period



period of time.









Material safety data sheets on all chemicals (or mixtures) and pesticides used in this employee’s area



during the following period of time.









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.



Monitoring results of chemical exposure levels in this work area or similar area including your copy of



measurements done in-house, by contract, or by your insurer, anytime before the following period of time:











A description of your Hazard Communication (Right to Know) Training Program. 







Measurements to evaluate local exhaust ventilation for this work area.  







Measurements of noise levels in this area.  








Medical monitoring information done by or for you on this employee, including:  





         Any study of problems or hazards including this work area.






         The schedule or records documenting pesticide applications in the patient’s/employee’s building.














Authorization Signature:


Date of Birth:



Employee/Patient Name


Social Security #:



Employee/Patient Address:












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.




  (This form is not under copyright)

  Copyright 2005-2006, Chemical Injury.NET  All Rights Reserved