Janitorial Department Work History
Please answer the questions below exactly as asked. Include all dates, names, descriptions, and any details you can recall. Your answers are sworn to be true to the best of your knowledge as if you were testifying in open court.
Work History and Exposure Details
Name
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First Name
Last Name
Employer (if a contractor, include full legal name). If you were employed by multiple employers identify the names of each.
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On-site location where you worked
*
Approx. dates you worked at this location
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Month
-
Day
Year
Date
Duration of work at this location (include hours per day, days per week, and total time spent)
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Approx. dates you claim you were exposed to mercury at this location
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-
Month
-
Day
Year
Date
Job title and duties while working at this location. If your job title or duties changed over time or during different phases of facility operation, please explain in as much detail as possible.
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Phase of facility and/or sister facility operation
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Please Select
Production
Outage
Decommissioning/Demolition
Names of supervisors
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Names of co-workers / others present at this location
Average temperature during your work at this location
Injury, Incident, and Response Details
Do you claim you were injured as a result of chemical exposure while working at this location, including exposure to mercury?
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Yes
No
Describe each event involving actual or potential mercury exposure, including dates, what you were doing, who you were working around, and any other details you recall.
What did you do as a result of the exposure? Please include who you reported it to, documents you consulted, PPE requested, work habit changes, health care sought, and any use of showers or changes to clothing or shoes.
Were you provided additional PPE or were your work habits altered by your supervisor? Please explain.
Were you given any additional training, safety precautions, or testing for potential mercury exposure? Were you removed from the area, and if so, when did the removal happen and when did you return? Please explain.
Other Claims, Tools, Monitoring, Testing, and PPE
Did you make any other claim for injury or illness arising out of this job?
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Yes
No
If yes, describe the nature of the claim, approximate dates, and how it was resolved
What tools or equipment did you use while performing work at this location?
Did you wear a mercury monitoring device while working at this location?
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Yes
No
Don't recall
Were you tested for mercury as a result of working at this location or around the time you worked at this location?
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Yes
No
Don't recall
If yes, who ordered the mercury test?
If yes, were you ever removed from your duties because of the mercury test? If so, when?
If yes, indicate the dates or frequency of the mercury tests and the results
Were you offered personal protective equipment while working at this location?
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Yes
No
Don't recall
If yes, what personal protective equipment were you offered?
Paper masks
Coveralls
Supplied air
Boots
Shoes and/or shoe coverings
Full-face mask mercury respirator
Half-face mask mercury respirator
Full-face mask respirator
Half-face mask respirator
Chlorine escape respirator
Supplied air respirator
Tyvek suit
None
Other
Did you wear gloves while working at this location?
Yes
No
Don't Recall
Other
If yes or other, please describe the gloves (cloth, latex, silicone, other) or explain:
Did you wear company-issued clothes or over-clothes garments while working at this location?
Yes
No
Don't Recall
Other
If “yes” or “other,” please describe the garments or explain, including whether you were required to change out of the clothing before leaving the premises and what material(s) the garments were made of:
Did you wear respiratory gear of any kind while working at this Location (other than a chlorine escape respirator on your belt/hip)?
Yes
No
Don't Recall
Other
If yes or other, please describe the respiratory gear or explain:
Did you wear a chlorine escape respirator on your belt/hip while working at this Location?
Yes
No
Don't Recall
Other
If yes or other, please describe the respiratory gear or explain:
Did you wear any other PPE while working at this location?
What PPE was required, when was it required, and where was it required?
Did you wear all company-required PPE at all times when it was required while working at this location?
Yes
No
Don't Recall
If Yes, do you believe that, despite wearing the required PPE, you were nevertheless exposed to mercury? Please explain how .
If no, what required PPE did you not wear, were you unable to wear, or was unavailable at this location and how often/for how long, did you depart from wearing that required PPE?
Did you or anyone you were working around perform any line breaks while working at this location?
Yes
No
Don't Recall
What type of equipment did you or anyone you were working around perform line breaks on?
Did you or anyone you were working around at this location perform any drilling, sandblasting, cutting, or sawing on equipment, systems, or parts that you believe were contaminated with mercury?
Yes
No
Don't Recall
If “yes,” please explain:
Did you or anyone you were working around at this location perform any hot work on any parts, systems, or equipment that you believe were contaminated with mercury?
Yes
No
Don't Recall
If “yes,” please explain:
Did you or anyone you were working around at this location disassemble any systems or parts that you believe were contaminated with mercury?
Yes
No
Don't Recall
If “yes,” please explain, including what was done with any contaminated materials you, or others you were working with or around, disassembled:
Did you or anyone you were working around perform any mercury washing, recovery or clean-up at this location?
Yes
No
Don't Recall
If “yes,” please explain:
Were you provided with any warnings or training regarding health or safety hazards associated with your work at this location?
Yes
No
Don't Recall
If yes, please describe the warnings or training, including when, how, and by whom, such information or training was communicated/presented, or explained:
If you were exposed to mercury or tested for mercury exposure related to your job at this location, where you, as a result, provided with any additional information or training as a result of such exposure or testing?
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