> **HP-IHP-\_\_\_000**![](media/image1.png){width="1.5333333333333334in"
> height="0.5618055555555556in"}
>
> **Environmental, Safety, Health & Quality Directorate**
>
> **SHSD Industrial Hygiene**

## 

## Field Monitoring Skills Application 

## Job Performance Measure (JPM) Completion Certificate 

  --------------------------------------------------------- -------------
  Candidate's Name                                          Life Number:

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**IH
Topic:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Practical Skill Applied [During the Previous 12 Months]{.underline}**

**IH Professional**

+-------------+------------------------------------------+------------+
| **Criteria  |                                          |            |
| &           |                                          |            |
| Qualifying  |                                          |            |
| Performance |                                          |            |
| Standard**  |                                          |            |
|             |                                          |            |
| **Exposure  |                                          |            |
| Monitoring  |                                          |            |
| Report      |                                          |            |
| Content:**  |                                          |            |
| Prepared an |                                          |            |
| adequate    |                                          |            |
| number of   |                                          |            |
| Exposure    |                                          |            |
| Assessment  |                                          |            |
| Reports to  |                                          |            |
| d           |                                          |            |
| emonstrate- |                                          |            |
|             |                                          |            |
| 1.  **      |                                          |            |
| Planning:** |                                          |            |
|     Proper  |                                          |            |
|     hazard  |                                          |            |
|             |                                          |            |
|    analysis |                                          |            |
|     of the  |                                          |            |
|             |                                          |            |
|    sampler, |                                          |            |
|     the     |                                          |            |
|     area,   |                                          |            |
|     and the |                                          |            |
|     workers |                                          |            |
|     in the  |                                          |            |
|     area.   |                                          |            |
|             |                                          |            |
| 2.  **      |                                          |            |
| Analysis:** |                                          |            |
|     Based   |                                          |            |
|     on the  |                                          |            |
|             |                                          |            |
|    exposure |                                          |            |
|     level,  |                                          |            |
|     the     |                                          |            |
|     correct |                                          |            |
|     reco    |                                          |            |
| mmendations |                                          |            |
|     of      |                                          |            |
|             |                                          |            |
| engineering |                                          |            |
|             |                                          |            |
|   controls, |                                          |            |
|     adm     |                                          |            |
| inistrative |                                          |            |
|             |                                          |            |
|   controls, |                                          |            |
|     and     |                                          |            |
|     PPE.    |                                          |            |
|             |                                          |            |
| 3.  **R     |                                          |            |
| eporting:** |                                          |            |
|     N       |                                          |            |
| otification |                                          |            |
|     of      |                                          |            |
|             |                                          |            |
|  Employees, |                                          |            |
|     d       |                                          |            |
| istribution |                                          |            |
|     of      |                                          |            |
|             |                                          |            |
|    reports, |                                          |            |
|     rec     |                                          |            |
| ordkeeping, |                                          |            |
|     and     |                                          |            |
|     data    |                                          |            |
|     entry   |                                          |            |
|     re      |                                          |            |
| quirements. |                                          |            |
|             |                                          |            |
| **List the  |                                          |            |
| reports     |                                          |            |
| submitted   |                                          |            |
| by the      |                                          |            |
| candidate   |                                          |            |
| for         |                                          |            |
| evaluation  |                                          |            |
| (work       |                                          |            |
| conducted   |                                          |            |
| within the  |                                          |            |
| last 12     |                                          |            |
| months)**   |                                          |            |
+-------------+------------------------------------------+------------+
| **Date**    | **Title**                                | **         |
|             |                                          | Evaluation |
|             |                                          | by         |
|             |                                          | Q          |
|             |                                          | ualifier** |
+-------------+------------------------------------------+------------+
| 1.          |                                          |            |
|             |                                          | Acceptable |
|             |                                          |            |
|             |                                          | Un         |
|             |                                          | acceptable |
+-------------+------------------------------------------+------------+
| 2.          |                                          |            |
|             |                                          | Acceptable |
|             |                                          |            |
|             |                                          | Un         |
|             |                                          | acceptable |
+-------------+------------------------------------------+------------+
| 3.          |                                          |            |
|             |                                          | Acceptable |
|             |                                          |            |
|             |                                          | Un         |
|             |                                          | acceptable |
+-------------+------------------------------------------+------------+

**IH Technician**

+-------------+------------------------------------------+------------+
| **Criteria  |                                          |            |
| &           |                                          |            |
| Qualifying  |                                          |            |
| Performance |                                          |            |
| Standard**  |                                          |            |
|             |                                          |            |
| **Exposure  |                                          |            |
| Monitoring  |                                          |            |
| Events:     |                                          |            |
| Conducted** |                                          |            |
| in an       |                                          |            |
| adequate    |                                          |            |
| number of   |                                          |            |
| Exposure    |                                          |            |
| Assessment  |                                          |            |
| to          |                                          |            |
| d           |                                          |            |
| emonstrate- |                                          |            |
|             |                                          |            |
| 1.          |                                          |            |
|  **Exposure |                                          |            |
|     Mo      |                                          |            |
| nitoring:** |                                          |            |
|     proper  |                                          |            |
|             |                                          |            |
|    sampling |                                          |            |
|     was     |                                          |            |
|     done of |                                          |            |
|     the     |                                          |            |
|             |                                          |            |
|    sampler, |                                          |            |
|     the     |                                          |            |
|     area,   |                                          |            |
|     and the |                                          |            |
|     workers |                                          |            |
|     in the  |                                          |            |
|     area.   |                                          |            |
|             |                                          |            |
| 2.          |                                          |            |
|  **Sampling |                                          |            |
|     Pre     |                                          |            |
| cautions:** |                                          |            |
|     correct |                                          |            |
|             |                                          |            |
|   awareness |                                          |            |
|     of      |                                          |            |
|             |                                          |            |
|   potential |                                          |            |
|     co      |                                          |            |
| ntamination |                                          |            |
|     to the  |                                          |            |
|     sampler |                                          |            |
|     and the |                                          |            |
|     proper  |                                          |            |
|     PPE.    |                                          |            |
|             |                                          |            |
| 3.  **Met   |                                          |            |
| hodology:** |                                          |            |
|             |                                          |            |
|   knowledge |                                          |            |
|     of      |                                          |            |
|     where   |                                          |            |
|             |                                          |            |
|   equipment |                                          |            |
|     needed  |                                          |            |
|     for the |                                          |            |
|             |                                          |            |
|   procedure |                                          |            |
|     is      |                                          |            |
|             |                                          |            |
|    located, |                                          |            |
|     how to  |                                          |            |
|             |                                          |            |
|    properly |                                          |            |
|     sign it |                                          |            |
|     out.,   |                                          |            |
|     and how |                                          |            |
|     to use  |                                          |            |
|     it      |                                          |            |
|             |                                          |            |
| 4.  **Docum |                                          |            |
| entation:** |                                          |            |
|             |                                          |            |
|   correctly |                                          |            |
|     filling |                                          |            |
|     out IH  |                                          |            |
|             |                                          |            |
|  monitoring |                                          |            |
|     forms.  |                                          |            |
|             |                                          |            |
| **List the  |                                          |            |
| events      |                                          |            |
| submitted   |                                          |            |
| by the      |                                          |            |
| candidate   |                                          |            |
| for         |                                          |            |
| evaluation  |                                          |            |
| (work       |                                          |            |
| conducted   |                                          |            |
| within the  |                                          |            |
| last 12     |                                          |            |
| months)**   |                                          |            |
+-------------+------------------------------------------+------------+
| **Date**    | **Title**                                | **         |
|             |                                          | Evaluation |
|             |                                          | by         |
|             |                                          | Q          |
|             |                                          | ualifier** |
+-------------+------------------------------------------+------------+
| 1.          |                                          |            |
|             |                                          | Acceptable |
|             |                                          |            |
|             |                                          | Un         |
|             |                                          | acceptable |
+-------------+------------------------------------------+------------+
| 2.          |                                          |            |
|             |                                          | Acceptable |
|             |                                          |            |
|             |                                          | Un         |
|             |                                          | acceptable |
+-------------+------------------------------------------+------------+
| 3.          |                                          |            |
|             |                                          | Acceptable |
|             |                                          |            |
|             |                                          | Un         |
|             |                                          | acceptable |
+-------------+------------------------------------------+------------+

> I certify the candidate has satisfactorily performed each of the above
> listed steps and is capable of performing the task unsupervised.

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  Evaluator Signature:                                      Date:

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JPM Form (Preparation Date: Rev0 02/2006)