Sample Record Keeping Forms Page 4
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4Form 4. A sample work evaluation form
Evaluation of Work Affecting Asbestos-Containing Materials
Evaluation of Work Affecting Asbestos-Containing Materials
This evaluation covers the following maintenance work:
This evaluation covers the following maintenance work:
Location of work (address, building, room number(s), or general description):
Location of work (address, building, room number(s), or general description):
Date(s) of work:
Date(s) of work:
Description of work:
Description of work:
Work approval form number:
Work approval form number:
Evaluation of work practices employed to minimize disturbance of asbestos:
Evaluation of work practices employed to minimize disturbance of asbestos:
Evaluation of work practices employed to contain released fibers and to clean up the work area:
Evaluation of work practices employed to contain released fibers and to clean up the work area:
Evaluation of equipment and procedures used to protect workers:
Evaluation of equipment and procedures used to protect workers:
Personal air monitoring results (in-house worker or contract?):
Personal air monitoring results (in-house worker or contract?):
Worker Name
Worker Name
Results
Results
Worker Name
Worker Name
Results
Results
Handling or storage of ACM waste
Handling or storage of ACM waste
Signed:
Signed:
Date:
Date:
(Asbestos Program Manager)
(Asbestos Program Manager)
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