PNNL Contractor Employee Job Task Analysis Form

Name: Payroll Number Occupation:

Contractor: Manager Name: Phone:

Creation Date: Send To Medical Date: Effective Date: Essential Job Functions: List those functions/job tasks that are essential and necessary for the job to exist. 1. 2. 3. 4. 5. 6. Requires Medical Qualification or Screening No Yes 1. Driver With CDL □ □ 2. Respirator Wearer □ □ 3. High Magnetic Field Operator/Support □ □ 4. Designated First Aid Provider - Bloodborne Pathogen □ □ Other Exposure Information 1. Radiation Worker II (requires wearing protective clothing) □ □ 2. High Vibration □ □ 3. Thermal Stress; WBGT => 80F □ □ 4. Dusty Environments □ □ 5. Physically Stressful Environments □ □ 6. Bloodborne Pathogens □ □ 7. Laboratory Animals □ □ 8. Wildlife/Wild Animals □ □ 9. Beryllium Assigned Worker □ □ 10. Operate/potential exposure-Class 3B or IV L/L sys □ □ 11. Asbestos Class I, II, or III construction worker □ □

Exposure Potential Work Potential Exposure Hazards: The anticipated exposure level is None < OEL > OEL designated through choices defined in the legend box. Around 1. Arsenic Inorganic □ □ □ □ 2. Asbestos □ □ □ □ 3. Benzene □ □ □ □ 4. Beryllium □ □ □ □

0.0/sp00e190.doc Page 1 of 2 (2/07) 5. Cadmium Inorganic □ □ □ □ 6. Formaldehyde □ □ □ □ 7. Lead Inorganic □ □ □ □ 8. Noise □ □ □ □ 9. Laser Light □ □ □ □ 10. Paints/Resins □ □ □ □ 11. Welding □ □ □ □ 12. Carcinogens (if not checked elsewhere) □ □ □ □ 13. Particulates □ □ □ □ 14. Chlorinated Solvents □ □ □ □ 15. Other Solvents □ □ □ □ 16. Other Corrosives □ □ □ □ 17. Isocyanates □ □ □ □ 18. Epichlorohydrin □ □ □ □ 19. Chlorine □ □ □ □ 20. PCBs □ □ □ □ 21 Ammonia □ □ □ □ 22. Mercury □ □ □ □ 23. Other Chemicals □ □ □ □

0.0/sp00e190.doc Page 2 of 2 (2/07)