Lead — Employer-Specific Instruction Record
Use for federal general-industry work under 29 CFR 1910.1025. Complete with the employer’s qualified trainer using actual operations, exposure information and controls. This course does not cover construction, certify abatement work, make medical decisions or establish workplace compliance.
Employee: ____________________ Site/job: ____________________
Trainer and role: ____________________ Date: ____________________
| Required workplace information | Actual details, responsible person and completion status |
|---|---|
| Operations and locations that may expose this employee to lead | |
| Job-specific monitoring results and how employees receive results | |
| Engineering and work-practice controls; compliance program access | |
| Current written program and at-least-annual program review | |
| Assigned housekeeping methods and prohibited cleaning practices | |
| Protective clothing, changing, storage, laundering and disposal arrangements | |
| Handwashing, showering, eating and drinking facilities and restrictions | |
| Assigned respirator, required respiratory protection program and training | |
| Medical surveillance provider, access and employee notification process | |
| Medical removal protection, return-to-work and multiple physician review contacts | |
| Emergency reporting, evacuation and limits on assigned response | |
| Locations of the lead standard and appendices; employee access | |
| Initial/annual training dates and additional workplace instruction | |
| Questions answered by qualified personnel and remaining follow-up |
Use the licensed medical provider for medical questions and decisions. Do not enter private medical results in this training worksheet.
| Unresolved item | Owner | Completion date |
|---|---|---|
Employee acknowledgement: ____________________ Date: ____________
Trainer acknowledgement: ____________________ Date: ____________
Acknowledgement records participation and does not authorize unassigned work.