Benzene Safety — Workplace Review
Complete with your employer's designated trainer before relying on the course for your assignment. Record actual workplace information. This worksheet does not authorize hazardous work, emergency response, respirator use, or confined-space entry.
Employee: ____________________ Site/job/shift: ____________________
Employer: ____________________ Trainer/contact: ____________________
Date: ____________________
| Workplace information and instruction | Actual details, responsible person, or completion status |
|---|---|
| Employer's determination of coverage and any applicable exceptions | |
| Locations, materials and tasks where benzene is present | |
| Product identifiers and how to access current safety data sheets each shift | |
| Actual representative exposure results, averaging periods and dates | |
| Regulated-area boundaries, entrance warnings and authorized access | |
| Engineering controls, work practices and defect/change reporting | |
| Required protective clothing, gloves, eye/face protection and replacement supplies | |
| Selected respiratory protection, its limitations and benzene-specific element replacement instructions | |
| Required program preparation, fit testing and practical equipment instruction | |
| Ignition control, storage, transfer and hygiene procedures for the actual task | |
| How to report a release from safety; emergency contacts and alarm method | |
| Evacuation routes, assembly point and accountability procedures | |
| Emergency eyewash, washing facilities, medical assistance and exposure reporting | |
| Prohibited actions for employees not assigned and trained for emergency response | |
| Medical-surveillance coordinator and how covered employees receive required evaluations | |
| Access to the benzene standard and explanations of Appendices A, B and C | |
| Access to written exposure-reduction program, monitoring results and applicable records | |
| Monitoring observation arrangements and required observer protection | |
| Initial training, annual training when exposure is above the action level, and additional applicable instruction |
Do not enter diagnoses, laboratory results, medication lists or confidential medical history on this worksheet. Discuss those through the authorized medical process. Online training is not medical clearance or a substitute for employer duties.
| Unresolved item | Owner | Required follow-up and completion date |
|---|---|---|
Employee acknowledgement: ____________________ Date: ____________
Trainer acknowledgement: ____________________ Date: ____________
Acknowledgement records the review; it is not a declaration of regulatory compliance or authorization to perform work. Resolve missing task information and required preparation with the employer before work.