<p> EJTA Business Sensitive 4/27/2018 Resp. Co: HID: Name: Status: EJTAID:</p><p>HR Manager Name: Prime Contractor: Org Code: Level 2 Subcontractor: Tracking Code: Level 3 Subcontractor: Primary Area: Job Title: Other Area Info: COCS: Shift: Occupation Other Shift Info: Admin. Employer:</p><p>Signatures Name: Date:</p><p>Manager:</p><p>Industrial Hygienist:</p><p>Employee:</p><p>Creation Date: Send To Medical Date: Effective Date: Essential Functions 1: </p><p>2: </p><p>3: </p><p>4: </p><p>5: </p><p>6: </p><p>7: </p><p>8: </p><p>Comments:</p><p>1 Resp. Co: HID: Name: Status: EJTAID:</p><p>Medical Qualifications 1 Crane Operator Yes 2 DOT Medical needed for CDL license or CMV driver Yes 3 Fissile Material Handler Yes 4 Respirator Wearer Yes 5 Human Reliability Program Yes 6 Quality Control Inspector Yes 6a AWS Vision Test Yes No 7 Nuclear Reactor Operator Yes 8 Tower Climber Yes 9 Hanford Patrol Yes 9a Security Officer Yes No 9b Hanford Patrol Security Police Officer I Yes No 9c Hanford Patrol Security Police Officer II Yes No 9d Hanford Patrol Security Police Officer III Yes No 10 Firefighter Yes 10a HAZMAT Yes No 11 Underwater Diver (Select one type below) Yes 11a Scientific Diver (NOAA) Yes No 11b Commercial Diver Yes No 12 OCRWM Testing Activities Per TN 8-027 (K Basins) Yes 13 High Magnetic Field Operator/Support (PNNL Only) Yes 14 Biological Safety Level 2 Laboratory Worker (PNNL Only) Yes 15 Engineered Nanoparticle Worker (PNNL Only) 16 Security Officer (PNNL Only)</p><p>2 Resp. Co: HID: Name: Status: EJTAID:</p><p>Other Exposure Information 1 Radiation Worker II Yes 2 High Vibration Yes 3 Licensed Pesticide Applicator Yes 4 Greenhouse Work: WBGT 80F Yes 5 Impermeable Clothing Yes 6 Physically Stressful Environments Yes 7 Bloodborne Pathogens Yes 7a Communicable Disease (e.g. Health Care Worker) Yes 7b AMH Clinic MTV Medical Qualification (Only If 7a is YES) Yes 7c N95 Resp for Health Care Workers (Only If 7a is YES) Yes 8 Routinely work within a RCRA/CERCLA boundary Yes 9 Work within a Tank Farm RCRA/CERCLA boundary Yes 10 Laboratory Animals Yes 10a Laboratory Animal Handler Yes No Only if 10 is 10b Primate Worker – General Yes No Yes 10c Cold Blooded Animal Yes No 11 Wildlife/Wild Animals Yes 11a Wild Mammal Handler Yes No Only if 11 is 11b Fowl/Avian Worker Yes No Yes 12 Member of PHMC Facility Emergency Response Org. (ERO)? Yes 12a Supports Emergency Response Only at the Incident Yes No Command Post? Only if 12 is 12b Supports Emergency Response at the EVENT Yes No Yes Scene? 13 Beryllium Worker Yes 14 Operate/potential exposure-Class 3B or IV L/L System Yes (not L pointer) 15 Asbestos Class I, II, or III Construction Worker Yes 15a Year of First Exposure 16 Tank Farm Entry Required Yes 17 ATL ONLY - 29 CFR 1910.1450 for Beryllium Yes 17a Be Medical Monitoring Yes No</p><p>3 Resp. Co: HID: Name: EJTAID:</p><p>Potential Exposure Hazards 0: Does Not Work With or Around 2: ≥Criteria for <30 Days/Year 1a: Potential, Works Around 3: >Criteria for ≥30 Days/Year 1b : <10% of Criteria Qd: Quantitative Data Available 1c: 10% of Criteria to <Criteria Hz: Hazardous Waste Related Y 0 1a 1b 1c 2 3 Qd Hz 1 Arsenic Inorganic 0 1a 1b 1c 2 3 Hz 2 Asbestos 0 1a 1b 1c 2 3 Hz 2a Year of First 3 BenzeneExposure 0 1a 1b 1c 2 3 Hz 4 Beryllium 0 1a 1b 1c 2 3 Hz 5 Cadmium Inorganic 0 1a 1b 1c 2 3 Hz 6 Formaldehyde 0 1a 1b 1c 2 3 Hz 7 Chromium (Hexavalent) 0 1a 1b 1c 2 3 Hz 8 Lead Inorganic 0 1a 1b 1c 2 3 Hz 9 Noise 0 1a 1b 1c 2 3 Hz 10 Laser Light 0 1a 1b 1c 2 3 Hz 11 Paint/Resins 0 1a 1b 1c 2 3 Hz 11a Lead 0 1a 1b 1c 2 3 Hz 11b Solvents 0 1a 1b 1c 2 3 Hz 12 Welding No 12a Nickel (SS) 0 1a 1b 1c 2 3 Hz 12b Other 0 1a 1b 1c 2 3 Hz Welding 13 Carcinogens No (if not checked elsewhere) 13a A1 or OSHA 0 1a 1b 1c 2 3 Hz 13b Other 0 1a 1b 1c 2 3 Hz 14 ParticulatesCarcinogens No 14a Coal Dust 0 1a 1b 1c 2 3 Hz 14b Synthetic 0 1a 1b 1c 2 3 Hz 14c OtherVitreous 0 1a 1b 1c 2 3 Hz 15 ChlorinatedPaticulates Solvents 0 1a 1b 1c 2 3 Hz 16 Other Solvents 0 1a 1b 1c 2 3 Hz 17 Other Corrosives 0 1a 1b 1c 2 3 Hz 18 Isocyanates 0 1a 1b 1c 2 3 Hz 19 Epichlorohydrin 0 1a 1b 1c 2 3 Hz 20 Chlorine 0 1a 1b 1c 2 3 Hz 21 PCBs 0 1a 1b 1c 2 3 Hz 22 Ammonia 0 1a 1b 1c 2 3 Hz 23 Mercury 0 1a 1b 1c 2 3 Hz 24 Other Chemicals 0 1a 1b 1c 2 3 Hz</p><p>4 Resp. Co: HID: Name: Status: EJTAID:</p><p>Physical Job Demands 0:Never 1:Rarely 2:Occasionally, Up to 1/3 of the Time 3:Frequently >1/3 of the Time Q:Job Requirement Yes/No 0 1 2 3 Q 1 Sitting 0 1 2 Q 2 Standing 0 1 2 Q 3 Walking (Even Surfaces) 0 1 2 Q 4 Walking (Uneven Surfaces) 0 1 2 Q 5 Running 0 1 2 Q 6 Crawling 0 1 2 Q 7 Climbing Legs Only 0 1 2 Q 8 Climbing (Hands and Legs) 0 1 2 Q 9 Twisting 0 1 2 Q 10 Straight Pulling 0 1 2 Q 11 Pulling Hand Over Hand 0 1 2 Q 12 Pushing 0 1 2 Q</p><p>13 Fine Finger Movement (Not Keyboarding/Mousing) 0 1 2 Q 14 Uses Both Hands 0 1 2 Q 15 Uses Both Legs 0 1 2 Q 16 Operating Motor Vehicles 0 1 2 Q 17 Operating Heavy Equipment 0 1 2 Q 18 Operating Machinery 0 1 2 Q 19 Material Handling Equipment 0 1 2 Q 20 Confined Areas 0 1 2 Q 21 Work in Hot Environments 0 1 2 Q 22 Work in Cold Environments 0 1 2 Q 23 Use of Foot Pedal/Foot Controls 0 1 2 Q 24 Above Shoulders Work 0 1 2 Q 25 Instrument Scan/Survey Yes No 25a Instrument Walking Stick 0 1 2 Q 25b Instrument Equipment <5 lbs 0 1 2 Q 25c Instrument Equipment 5 – 10 lbs 0 1 2 Q 25d Instrument Equipment >10 – 20 lbs 0 1 2 Q 25e Instrument Equipment >20 lbs 0 1 2 Q 26 Lifting >10 lbs Yes No 26a Lifting >75 lbs 0 1 3 Q 26b Lifting >55 75 lbs 0 1 3 Q 26c Lifting >25 55 lbs 0 1 3 Q 26d Lifting >10 25 lbs 0 1 3 Q 27 Carrying >10 lb Yes No 27a Carrying >75 lb 0 1 3 Q 27b Carrying >55 75 lb 0 1 3 Q 27c Carrying >25 55 lb 0 1 3 Q</p><p>5 Resp. Co: HID: Name: Status: EJTAID:</p><p>0:Never 1:Rarely 2:Occasionally, Up to 1/3 of the Time 3:Frequently >1/3 of the Time Q:Job Requirement Yes/No 0 1 2 3 Q 27d Carrying >10 25 lb 0 1 3 Q 27e Carrying - Single Hand 0 1 3 Q 28 Highly Repetitive Activites Yes No 28a Intense Keying/Mousing >4 hr/shift Yes No 28b High Rep.-Other Activities >2 hr/Shift Yes No 29 Kneeling Yes No 29a Kneeling-Greater Than 2 hr/Shift Yes No 30 Crouching/Squatting Yes No 30a Crouching- >2 hr/Shift Yes No 31 Bending Neck or Back >30 degrees Yes No 31a W/O Support or Varying Yes No Posture >2 hr/Shift 32 Hand Grip 10-lb Force or Objects >2 hr/Shift Yes No 33 Finger Pinch 4-lb Force or 2lb Object Yes No 33a Finger- >2 hr/Shift Yes No 34 Hand/Arm Vibration Yes No 34a Hand- High >30 min/Shift (i.e., Jack Hammer) Yes No 34b Hand- Moderate >2 hr/Shift (i.e., Sander) Yes No</p><p>35 Repeated Impact W/Hand/Knee as Yes No Hammer 35a Repeated- >2 hr/Shift Yes No</p><p>General Managers, Executives, First line Supervisors & Program/Project managers M010 First Line Supervisors M020 General Managers and Executives M030 Project and Program Managers M040 Other Managers Engineers E010 Chemical Engineers E020 Civil Engineers E030 Computer Engineers E040 Electrical Engineers E050 Environmental Engineers E060 Industrial Engineers E070 Mechanical Engineers E080 Nuclear Engineers E090 Petroleum / Mining Engineers E100 Plant Engineers E110 Quality Control Engineers E120 Safety Engineers E130 Other Engineers Scientists S010 Chemist S020 Environmental Scientist S030 Geologist S040 Life Scientists S050 Materials Scientists S060 Mathematician 6 S070 Physicist S080 Social Scientists S090 Other Scientists Administrative and Other Professional Occupations P010 Accountants and Auditors P020 Architects P030 Buyers, Procurement and Contracting Specialists P040 Communication Specialists P050 Compliance Inspectors P060 Computer Systems Analysts P070 Costs Estimators and Planners and Schedulers P080 Health Physicists P090 Industrial Hygienists P100 Lawyers P110 Personnel and Labor Relations Specialists P120 Physicians P130 Physician Assistants, Nurses and Other Medical Support Occupations P140 Safeguards and Other Security Specialists P150 Trainers P160 Technical Writers and Editors P170 Other Administrative and Professional Other Occupations General Administrative, Secretarial and Clerical Support Staff G010 Administrative Assistants G020 Office Clerks (General) G030 Office Clerks (Specialized) G040 Secretaries G050 Typists and Word Processors G060 Other General Administrative, Secretarial and Clerical Support Staff Technicians T010 Computer Operators/Coders T020 Drafters T030 Engineering Technicians T040 Environmental Sciences Technicians T050 Health Physics Technicians T060 Industrial Safety and Health Technicians T070 Instrument and Control Technicians T080 Laboratory Technicians T090 Media Technicians T100 Survey and Mapping Technicians T110 Other Technicians Crafts C010 Carpenters C020 Electricians C030 Heating Air-Conditioning and Refrigeration Mechanics (HVAC) C040 Machinists C050 Masons C060 Millwrights C070 Painters C080 Plumbers and Pipefitters C090 Structural and Metal Workers C100 Vehicle and Mobile Equipment Mechanics C110 Welders C120 Other Crafts Operators R010 Chemical System Operators R020 Drillers R030 Material Moving Equipment Operators 7 R040 Nuclear Plant Operators R050 Nuclear Waste Process Operators R060 Production Systems Operators R070 Utilities Systems Operators R080 Other Operators Laborers and General Service Workers L010 Firefighters L020 Food Service Workers L030 Janitors and Cleaners L040 Laundry Workers L050 Material Handlers, Helpers and Laborers (General) L060 Material Handlers, Helpers and Laborers (Specialized) L070 Light Vehicle Drivers L080 Security Guards L090 Other Laborers and General Services Workers</p><p>8 A1 or OSHA Carcinogens 2-Acetylaminofluorene Chromite Ore Processing (Chromate) 3,3'-Dichlorobenzidine (and its salts) Coal Tar Pitch Volatiles as Benzene Solubles 4-Aminodiphenyl Ethyleneimine 4-Dimethylaminoazo-Benezene Insoluble Cr VI Compounds, NOC 4-Nitrobiphenyl Methyl Chloromethyl Ether Alpha-Napthylamine Nickel Sulfide Roasting, Fume and Dust Benzidine N-Nitrosodimethylamine Beta-Naphthylamine Vinyl Chloride Beta-Propiolactone Water Soluble CrVI Compounds, NOC Bis-Chloromethyl Ether Zinc Chromates</p><p>Other Carcinogens Lindane and Other Hexachlorocyclohexane Regulated Carcinogens: Isomers 2-Nitropropane Melphalan 3,3-Dimethoxybenzidine & 3,3- Dimethoxybenzidine 2HCl Methoxsalen with Ultraviolet A Therapy (Puva) 3,3-Dimethylbenzidine Methyl Iodide 3-Chloro-2-Methylpropene Methylene chloride 4-(N-Nitrosomethyl-Amino)-I-(3-Pyridyl)-L- Butanone(NNK) Michler's Ketone 4,4-Methylene Bis (2-Chloroaniline)(MOCA) (MBOCA) Mirex 4-Chloro-O-Phenylenediamine Nickel and Certain Nickel Compounds Acetaldehyde N-Nitrosodiethanolamine Acrylonitrile N-Nitrosodiethylamine Benzo(B)Fluoranthene N-Nitrosodi-N-Butylamine Bromodichloromethane N-Nitrosodi-N-Propylamine Butylated Hydroxyanisole N-Nitrosomethyl-Vinylamine C.I. Basic Red 9 Monohydrochloride N-Nitrosomorpholine Calcium Chromate N-Nitroso-N-Ethylupea Carbon Tetrachloride N-Nitroso-N-Methylurea Ceramic Fibers (Respirable Size) N-Nitrosonornicotine Chlorambucil N-Nitrosopiperidine Chlorinated Paraffins (C 2, 60% Chlorine) N-Nitrososarcosine Diethyl sulfate Ochratoxin A Diethyl sulfate O-Toluidine and O-Toluidine Hydrochloride Diethylstilbestrol P-Cresidine Diglycidyl Resorcinol Ether Phenazopyridine Hydrochloride Dimethyl Carbamoyl chloride Pheylhydrazine Dimethyl Sulfate Polybrominated Biphenyls Dimethylvinyl chloride Propane Sultone Dinitrotoluene Saccharin Direct Black 38 Safrol Direct Blue 6 Selenium Sulfide Erionite Silica Estrogens (Not conjugated) Estrone Streptozotocin Estrogens (Not conjugated):Estradiol-17 Beta Sulfallate Estrogens (Not conjugated):Ethinylestradiol Tetrachloroethylene (Perchloroethylene) Estrogens (Not conjugated):Mestranol Tetranitromethane Ethylene Oxide Thioacetamide Glasswool (Respirabel size) Thiourea Glycidol Thorium Dioxide Gexamethyl Phosphoramide Toluene Diisocyanate Hydrazine and Hydrazine Sulfate Toxaphene Hydrazobenzene Tris(1-Aziridinyl)Phosphine Sulfide (Thiotepa) Iron Dextran Complex Tris(2,3-Dibromopropyl) Phosphate Kepone**(Chlordecone) Vinyl Cyclohexene 9 Lead Acetate and Lead Phosphate Vinyl Cyclohexene Dioxide Lead Chromate Xylidine (Mixed Isomers)</p><p>10 Other Carcinogens: (2-Chloroehtyl)-3-(4-Methylcyclohexyl)-l-Nitrosour- Ea(MECCNU) 1-(2-Chloroethyl)3-Cyclohexyl-1- Nitrosourea(CCNU) 1,1-Dimethylhydrazine 1,2-Dibromoethane (Ethylene Dibromide) 1,2-Dichloroethane 1,3-Butadiene 1,3-Dichloropropene(Technical Grade) 1,3-Propane Sultone 1,4-Butanediol Dimethyl-Sulfonate (Myleran) 1,4-Dichloro-2-Butene 1,4-Dichlorobenzene 2,4-Diaminoanisole Sulfate 1,4-Dioxane 2,4-Diaminotoluene 1-Amino-2-Methylanthraquinone 2-Aminoanthraquinone 2,3,7,8-Tetrachlorodibenzo-12-Dioxin(TCDD) 2-Methylaziridine(Propyleneimine) 2,4,6-Trichlorophenol 2-Napthylamine Solvents - Solvent Program Other Solvents - Solvent Program Acetone Acetone Benzene Butanol Ethanol Cellosolves Ethyl Acetate Ethanol Hexane(s) Ethers Hydrocarbons Ethyl Acetate Isopropyl Acetate Gasoline Methanol Hexane Methyl Ethyl Ketone Hydrocarbons Methyl Isobutyl Ketone Isopropanol Mineral Spirits Isopropyl Acetate Other Methanol Petroleum Distillates Methyl Ethyl Ketone Toluene Mineral Spirits Xylene Maptha Other Carcinogens - Solvent Program Petroleum Distillates Benzene Phenol Carbon Tetrachloride Toluene Chloroform Tributyl Phosphate Ethylene Dibromide Turpentine Methylene Chloride VM&P Naptha Tetrachloroethylene Xylene Chlorinated Solvents – Solvent Program 3Other Corrosives Category: 1,1,1-Trichloroethane Acetic Acid (Glacial) 1,1,2-Trichloroethane Ammonium Hydroxide Carbon Tetrachloride Formic Acid Chloroform Hydrochloric Acid Ethylene Dichloride Hydrofluoric Acid Freon 113 Nitric Acid Tetrachloroethylene Phosphoric Acid Trichloroethane Potassium Hydroxide Freons and Halons Sodium Hydroxide Methylene Chloride Sulfuric Acid Other Welding Aluminum Copper Tin Antimony Iron Tungsten Arsenic Lead Vanadium Cadmium Manganese Zinc Cobalt Selenium 11 12</p>