**RESPIRATORY PROTECTION -- Does your employee perform, or work in proximity to, any of the following job tasks or processes? Y N**                                                                                   
  ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- --
  Use any workplace product that states on the label or MSDS that respiratory protection is required                                                                                                                    
  Spray paint, insecticides, herbicides or other flammable or toxic chemicals in pressurized/mist form                                                                                                                  
  Weld, braze, solder, or use a torch to cut metals                                                                                                                                                                     
  Grind metals, sand wood, clean with air pressure, sandblast, or other process that generates dust                                                                                                                     
  Use petroleum or alcohol based solvents?                                                                                                                                                                              
  Handle biological samples or the remains of dead animals?                                                                                                                                                             
  Clean or demolish old or abandoned structures?                                                                                                                                                                        
  Enter confined spaces?                                                                                                                                                                                                
  Voluntarily use (i.e., when workplace measurements don't support requiring them to do so) a respirator of any type, including disposable dust masks? (If "yes,\" see below)                                           
  NOTE: Employees voluntarily using any type of respiratory protection must be provided a copy of 29 CFR 1910.134, Appendix D, *Information for Employees Using respirators When Not Required Under the Standard*.      

  **HEARING CONSERVATION - Does your employee work directly with, or in the vicinity of, any of the following types of equipment as part of their job?** **Y N**      
  ---------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --
  Lawnmower, leaf blower or weed trimmer                                                                                                                              
  Gas powered chainsaw, drill, or jackhammer                                                                                                                          
  Gas powered fuel or water pump, compressor, or generator                                                                                                            
  Powered wood shop tool (tablesaw, planer, jointer, bandsaw, sander, shaper, etc.)                                                                                   
  Electric or air powered portable tool that cuts, drills, routs, or hammers                                                                                          
  Grinding wheel/disk                                                                                                                                                 
  Firearms or explosives                                                                                                                                              
  ATV, outboard boat motor,                                                                                                                                           
  Helicopter or non-commercial fixed wing aircraft                                                                                                                    
  Heavy equipment ( grader, backhoe, bucket loader, compactor, etc.                                                                                                   
  Skid steer tractor , diesel or gas forklift                                                                                                                         
  Any other comparably loud equipment/processes                                                                                                                       

  **BLOODBORNE PATHOGENS -- Does your employee perform any of the following tasks? Y N**                       
  --------------------------------------------------------------------------------------------------------- -- --
  Work in remote areas with no emergency services readily available (i.e., serve as a 1^st^ Aid provider)      
  Pick up or handle garbage, trash, medical waste, or feces, either bagged or unbagged?                        
  Clean used eating utensils                                                                                   
  Clean bathrooms or outhouses                                                                                 
  Serve as an EMT on fire/incident crews                                                                       
  Handle biological specimens or the remains of dead animals                                                   
  Operate a sewage treatment system                                                                            
  Repair plumbing pipes or fixtures                                                                            

+------------------------------------------------------------+---+---+
| **LOCK-OUT/TAG-OUT (ENERGY CONTROL) -- Does your employee  |   |   |
| perform any of the following job tasks? Y N**              |   |   |
+============================================================+===+===+
| Install, repair, or replace electrical circuitry switches, |   |   |
| or devices connected in any way to utility line or         |   |   |
| portable generator power of 110 volt AC or greater         |   |   |
+------------------------------------------------------------+---+---+
| Install, repair, or replace electrical circuitry switches, |   |   |
| or devices connected to DC power beyond that created by    |   |   |
| disposable batteries                                       |   |   |
|                                                            |   |   |
| (Actual hazard level must be determined by measuring       |   |   |
| amperage & voltage)                                        |   |   |
+------------------------------------------------------------+---+---+
| Repair or perform maintenance on tools or equipment with   |   |   |
| moving parts                                               |   |   |
+------------------------------------------------------------+---+---+
| Replace blades or bits on machinery                        |   |   |
+------------------------------------------------------------+---+---+
| Work under any object supported by lifts or jacks          |   |   |
+------------------------------------------------------------+---+---+
| Any servicing or maintenance on any other machine or       |   |   |
| equipment where the unexpected energizing, start up, or    |   |   |
| release of stored energy could occur and cause injury      |   |   |
+------------------------------------------------------------+---+---+

  **CONFINED SPACE ENTRY -- Does your employee enter any space that: Y N**                                                                                                 
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --
  Can be physically entered, but is not designed for continuous employee occupancy (examples: silos, bins, hoppers, vaults, pits, manholes, crawlspaces, tanks)            
  Has limited or restricted means for entry or exit (a hatchway or hole that is less than a standard doorway in size or otherwise obstructs entry or exit in any way)      

  **HAZARD COMMUNICATION (HAZCOM) Y N**                                                                                                                                                                                                                                                                                                                  
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --
  Does your employee use a chemical product?                                                                                                                                                                                                                                                                                                             
  Is your employee exposed to a chemical product used by other employees?                                                                                                                                                                                                                                                                                
  NOTE: Basically, any product/substance is a chemical product. The health hazard of a product is determined by degree of toxicity and length of exposure. The use of a product at the level of a typical household consumer may not require a program. Consult your safety specialist for guidance on your particular workplace chemical products.      

  **Emergency Action Plan --** Does your Emergency Action Plan fail to address any of the following points: **Y N**      
  ------------------------------------------------------------------------------------------------------------------- -- --
  Fires, chemical spills, sabotage, civil disobedience, bomb threats, natural disaster                                   
  Emergency reporting procedures                                                                                         
  Building evacuation routes                                                                                             
  Procedures to account for evacuated employees                                                                          
  Emergency duties assigned to named individuals                                                                         
  Names and job titles of emergency procedures personnel                                                                 

  **Fire Prevention Plan --** Does your facility: **Y N**                            
  ------------------------------------------------------------------------------- -- --
  Require all employees to evacuate immediately when a fire alarm sounds             
  Have fire extinguishers stationed for employee use                                 
  Have any quantity of ethylene oxide, *Methylenedianiline*, or *1,3-Butadiene*      

+------------------------------------------------------------+---+---+
| **Radiation Control Plan --** Is your employee exposed to  |   |   |
| any of the following **potential** sources of **ionizing** |   |   |
| radiation :                                                |   |   |
|                                                            |   |   |
| **Y N**                                                    |   |   |
+============================================================+===+===+
| Metal mining, ores & processing waste                      |   |   |
+------------------------------------------------------------+---+---+
| Oil and Gas Production Wastes                              |   |   |
+------------------------------------------------------------+---+---+
| Coal ash                                                   |   |   |
+------------------------------------------------------------+---+---+
| Phosphate waste                                            |   |   |
+------------------------------------------------------------+---+---+
| Uranium mining ore samples or overburden                   |   |   |
+------------------------------------------------------------+---+---+
| Water Treatment Residues                                   |   |   |
+------------------------------------------------------------+---+---+
| X-Ray machines (e.g., pipeline weld analyzer)              |   |   |
+------------------------------------------------------------+---+---+
| Areas of naturally high ambient radiation levels           |   |   |
+------------------------------------------------------------+---+---+
| Portable moisture or density meters                        |   |   |
+------------------------------------------------------------+---+---+
| Well logging devices                                       |   |   |
+------------------------------------------------------------+---+---+

  **PERSONAL PROTECTIVE EQUIPMENT (PPE) -- Is your employee exposed to: Y N**                                                                                                                                                                            
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --
  Flying particles, molten metal, liquid chemicals, acids or caustic liquids, chemical gases or vapors                                                                                                                                                   
  Welding arc or other intense light                                                                                                                                                                                                                     
  Dusts, fogs, vapors, fumes, mists, gases, smokes, or sprays (See ***Respiratory Protection***, other side)                                                                                                                                             
  Loud noises (see ***Hearing Protection***, other side)                                                                                                                                                                                                 
  Overhead objects that could fall and cause head injury (construction tools and materials, forest trees/branches, warehouse materiel)                                                                                                                   
  Electrical energy                                                                                                                                                                                                                                      
  Hazards to the hands from burns, cuts, abrasions, punctures, chemical exposures or cryogenic liquids/gases                                                                                                                                             
  Bloodborne pathogens or other biological hazards (See ***Bloodborne Pathogens***, previous page.)                                                                                                                                                      
  Chainsaw blades                                                                                                                                                                                                                                        
  Extreme environmental conditions                                                                                                                                                                                                                       
  Operation of off highway vehicles or watercraft                                                                                                                                                                                                        
  Working at heights greater than 4' for general activities or 6' if engaged in building construction.                                                                                                                                                   
  NOTE: PPE should not be provided (and employees should not be exposed to the hazard requiring it) without completing a hazard assessment and a program that addresses employee training and selection, fit, cleaning, and maintenance of the PPE.      

  **Other serious workplace hazards may also justify written programs, though OSHA may not specifically identify or even require them. The BLM uses such programs to help manage risk in various hazardous activities. Does your employee engage in any of the following workplace activities:** **Y N**      
  -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --
  Tower climbing                                                                                                                                                                                                                                                                                              
  Duties with exposure to non-ionizing radiation (radar, radio, or electromagnetic force)                                                                                                                                                                                                                     
  Cave or abandoned mine entry                                                                                                                                                                                                                                                                                
  Powered or non-motorized watercraft operation                                                                                                                                                                                                                                                               
  Non-law enforcement related firearms use                                                                                                                                                                                                                                                                    
  Special purpose aviation flights                                                                                                                                                                                                                                                                            
  Wild animal capture                                                                                                                                                                                                                                                                                         
  Rock climbing/rappelling                                                                                                                                                                                                                                                                                    
  Off Highway Vehicle (OHV) operation