Exposure To Health Risks Physical Demands Form
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7MICHIGAN STATE UNIVERSITY
EXPOSURE TO HEALTH RISKS/PHYSICAL DEMANDS FORM
Start date: _____/_____/_____
Date: ______/______/______
Employee Name: __________________________________________________
DOB: ______/______/______
Department Name: __________________________________________ Job Position: ______________________
Department Account #: ______________ Supervisor: _______________________________________________
Telephone: ______________________ Fax: _____________________ E-mail: ____________________________
Please review the Exposure to Health Risks and Physical Demands section and check appropriate risk(s). Every risk
checked requires medical monitoring and /or training. The supervisor is responsible for coordinating the required
initial and periodic monitoring and/or training. REVIEW RISK INFORMATION (starting on pg. 3) BEFORE CHECKING
ANY BOX. This completed form must be sent in advance of medical monitoring and/or training to MSU Occupational
Health, Room 346 Olin Health Center by mail, by fax to 355-0332, or as an e-mail attachment to
occhealth@ht.msu.edu
with the employee’s name in the subject line.
EXPOSURE TO RISKS SECTION
1. □ Exposure to human blood, serum, tissue and other body fluids; and materials covered under Universal
Precautions.
2. □ TB risk or work within 3 feet of human patients in a health care setting or have potential exposure to animals
or to specimens with Mycobacterium.
3. □ Work with animals or unfixed animal tissue.
4. □ Drive a university vehicle, which requires a commercial driver’s license:
VEHICLES:
o
Having a gross vehicle weight or weight rating (GVWR) of 26,001 pounds or more.
COMBINATION VEHICLES:
o
Towing a trailer or other vehicles with a GVWR of 10,001 pounds or more and a gross combination weight
or weight rating of 26,001 pounds or more.
ANY VEHICLES:
o
Designed or used to transport more than 8 passengers (including the driver) for compensation.
Designed to transport 16 or more people (including the driver).
Carrying hazardous materials in amounts requiring placards.
5. □ Drive a university vehicle that does not require a commercial driver’s license but does require medical
certification:
VEHICLES:
o
Have a gross vehicle weight or weight rating (GVWR) of 10,001 pounds or more but less than 26,001
pounds.
COMBINATION VEHICLES:
o
Having a combined gross vehicle weight or weight rating (GVWR) of 10,001 pounds.
6. □ Wear a respirator (does not include paper dust mask worn for comfort).
7. □ Spray or mix organophosphate or carbamate insecticides.
□ Work in noisy (at or above 85 decibels) areas.
8.
□ Risks that have been identified by Environmental Health and Safety, such as exposure to lead, chemotherapy,
9.
formaldehyde, asbestos, etc.
Please list _______________________________________
10. □ Physically intensive job (does not apply to student employees), complete PHYSICAL DEMANDS SECTION.
(Please see explanation of items 1-10, starting on page 3)
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