School System Employee Exposure Report
Complete form and return to supervisor within 24 hours of exposure to any chemical at the worksite

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:________________________________________________
________________________________________________________________________________



________________________________________________
(exposed employee's signature & today's date)

________________________________________________
(supervisor's signature + print/type name of supervisor)