Hazard Evaluation for Respirator Use Request

Complete and submit this form to Environment, Health & Safety. An EH&S Industrial Hygienist will contact you.

By submitting this form you are stating that you have supervisor approval to request respirator training and are UCLA affiliated.

Your Information

First

Last

Email

Phone Number

Department

Building/Room

Supervisor

Supervisor's Email

Materials

Hazardous Material

Quantity/Each Use

Frequency of Use

Exposure Controls

Add More Hazardous Materials

Yes

No

Fill in up to 4 Hazardous Materials

2nd Hazardous Material

Hazardous Material

Quantity/Each Use

Frequency of Use

Exposure Controls

3rd Hazardous Material

Hazardous Material

Quantity/Each Use

Frequency of Use

Exposure Controls

4th Hazardous Material

Hazardous Material

Quantity/Each Use

Frequency of Use

Exposure Controls

Operations Description

CAPTCHA