Silica Dust Exposure Form – Austructure Forms

Name(Required)

First Last

Email(Required)

Phone(Required)

Were you exposed to silica dust this week?

Yes

No

Days exposed

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

What days were you exposed to silica dust? Select all that apply.

Saturday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Saturday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Sunday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Sunday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Monday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Monday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Tuesday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Tuesday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Wednesday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Wednesday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Thursday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Thursday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Friday Date

Please check this date and update accordingly.

Duration in minutes

Please enter the total duration of your exposure in minutes for the day. e.g. two and a half hours would be 150.

Comment

Please enter any comments about the exposure.

Friday Activities

Drilling

Cutting

Jack Hammer

Grinding

Please check all that apply for the day.

Other controls in place

Water suppression

Vacuum

Please check all that apply for the day.

Total Minutes

Total Days