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REPRODUCTIVE HEALTH CONSULTATION

Please print and mail this completed document to EHRS, 3160 Chestnut Street, Suite 400, Philadelphia, PA, 19104.

Name ________________________________________ Date ___________________________
Job Title ________________________________________ Department ___________________________
Supervisor ________________________________________ Location ___________________________

AGENTS USED AT WORK   (Do not use abbreviations for chemical names.)

List agents you are currently using or anticipate using during pre-conception or pregnancy. Frequency of use: daily, weekly, monthly, etc. State of the agent: solid, powder, liquid, gas, etc. Quantity used per unit time (e.g. 10g per week) Protective equipment: fume hood, gloves, lab coat, biosafety cabinet etc.
CHEMICAL AGENTS        
BIOLOGICAL AGENTS        
RADIATION AGENTS        

DESCRIBE THE PHYSICAL DEMANDS OF YOUR WORK:

Lifting: (# lbs, frequency)

Standing: (duration of time)

Noise:

Other:

DO YOU HAVE HEALTH OR SAFETY CONCERNS ABOUT A SPECIFIC ASPECT OF YOUR WORK? (If so, please describe):

HAVE YOU HAD ANY SPILLS OR UNINTENTIONAL EXPOSURES RECENTLY? (If yes, please describe):

NO

YES

DO YOU WEAR PERSONAL PROTECTIVE EQUIPMENT AT WORK?

Gloves NO   YES
Lab coat, uniform or other protective clothing NO   YES
Dust mask or respirator NO   YES
Eye protection NO   YES
Other_____________________________________ NO   YES

LABORATORY ENVIRONMENT: (If applicable)

How much time do you spend doing bench work? ______________________% office work? ______________________%
Where is your office located (in the lab or separate)? ________________________________________________________
Are other people working in the same laboratory room as you? ________________________________________________________
Where is your balance located (on the bench or in a hood)? ________________________________________________________