New Employee Exposure Assessment Form Directions: Complete all sections of the form. Select at least one category for each section. Check all statements that apply to your job. First Name: *   Last Name: *   Email Address: *   Start Date: (mm/dd/yyyy) *   Work Phone: *   Penn ID# (Middle 8 Numbers): *   Job Title: *   School/Department: *   Building:    Room #:    Mail Code:    Principal Investigator / Supervisor: *      * Required Fields   Section 1 : Chemical Safety Program Work Environment (check all that apply)      Training / Program Requirements Laboratory Environment       Introduction to Laboratory & Biological Safety at Penn Work Area Specific Training (by Supervisor) Non-Laboratory Environment   Clinical Environment   Physical Plant / Housekeeping       Hazard Communication Training (Email EHRS or call 215-898-4453) Work Area Specific Training (by Supervisor)   Section II : Noise Exposure / Hearing Conservation Work Environment (check one)      Training / Program Requirements Employee will not be exposed to noise > 85dB       None Employee may be exposed to noise > 85dB (animal care technicians, cage washers, nitrogen facility, mechanic, other)       Hearing Conservation Program Email Karen Kelley or call 215-573-9446   Section III : Respirators Work Environment (check all that apply)      Training Requirements Employee will not wear a respirator       None Employee will wear a respirator       Respiratory Protection Program Email Lisa Krause or call 215-746-6549   Section IV : Radiation Safety Program Exposure Criteria (Check all that apply)      Training Requirements Employee will not work in a lab with radioactive materials       None Employee will work in a lab with radioactive materials or in a lab where radioactive materials are used or stored   Employee will work with sealed sources, x-ray machines, electron microscopes, diffraction units, or irradiators       Complete Radiation Safety Training before beginning work   Section V : Laser Safety Program Work Environment (Check one)      Training Requirements Employee will not work with or around lasers       None Employee will work with or around lasers. Lasers Class (1,2,3a,3b,4)      Laser Safety Training for all laser users. Work Area Specific Training (by Supervisor) Medical Surveillance if Class 3b or 4 laser. Email Karen Kelley or call 215-898-4453   Section VI : Bloodborne Pathogens Program Exposure Criteria       Training / Program Requirements No reasonably anticipated exposure to human blood, body fluids, or other potentially infectious materials.      None Employee has a reasonably anticipated risk of exposure to human blood, body fluids, or other potentially infectious materials while conducting the following activities:  (check all that apply) Working in a research laboratory HIV/HBV research Clinical setting, direct patient care activities including: processing or handling of human blood. Processing or handling contaminated equipment materials or other potentially infectious materials. Routine administration of first aid. Other potential exposure to bloodborne pathogens:     Hepatitis B Vaccination recommended. Contact HUP Occupational Medicine for appointment, 215-662-2354. Sign a declination waiver if refusing vaccination. Introduction to Laboratory & Biological Safety at Penn Work Area Specific Training (by Supervisor) Contact EHRS or call 215-898-4453 for additional HIV/HBV research lab training requirments.   Section VII : Tuberculosis Exposure Prevention Program Exposure Criteria       Training / Program Requirements No likely or anticipated exposure to Mycobacterium tuberculosis (TB) as described below.      None Employee will work with or around non-human primates Employee has a reasonably anticipated risk of exposure to TB by conducting the following activities:  (check all that apply) Primary work assigned in patient care activities. Direct one-on-one contact with patients. Performs procedures with a high likelihood of aerosolization of clinical material potentially contaminated with TB (i.e., sputum inductions, bronchoscopy, irrigation of infected abscesses, aerozolized pentamidine administration). Performs laboratory procedures with a high likelihood of aerosolizing clinical specimens or cultures likely to contain TB (i.e., vortexing, homogenizing, lyophilizing). Other potential sources of exposure to TB:     Work Area Specific Training (by Supervisor) PPD skin test evaluation. Contact HUP Occupational Medicine for appointment, 215-662-2354.   Section VIII : Select Agents Exposure Criteria (Check one)      Training / Program Requirements Employee will not work with Select Agents       None Employee will work with Select Agents or will work in a lab where select agents are used or stored.       PI must update registration with EHRS and federal agency(ies) prior to obtaining Select Agents. Complete Select Agent Training program. Please contact EHRS or call 215-898-4453 for more details.   Section IX : Packaging & Shipping Infectious Materials Work Environment (Check one)      Training Requirements Employee will not be responsible for either packaging or shipping diagnostic specimes or infectious materials.     None Employee will package and/or ship diagnostic specimens or infectious materials.       Complete Shipping Training.   Section X : Vaccinia Virus Work Environment (Check all that apply)      Training Requirements Employee does not work with vaccinia virus     None Employee will work with highly attenuated vaccinia virus.       Work Area Specific Training Employee will work with "standard" vaccinia virus that can replicate in human cells.       Attend mandatory counseling with HUP Occupational Medicine prior to beginning work. Call 215-349-5514 for an appointment. Small pox vaccination is optional. Work Area Specific Training (by Supervisor).   Section XI : Research Animal Handling Work Environment (Check One)      Training Requirements Employee will not handle research animals.     None Employee will handle research animals.       Work Area Specific Training (by Supervisor) Orientation to Animal Research Employee will handle non-human primates.       Work Area Specific Training (by Supervisor) Orientation to Animal Research Contact Carol Pierce at HUP Occupational Medicine for appointment (215-662-4047)