TOTHEPREVENTIONANDPROTECTIONSERVICE

PLACEofWORKViaGramscin.17

NameSurname Born in Taxidentification number: Relevantorganisation: Placeof work:

Tel.Mob.e-mail Title Contracttype:

Graduationcandidates / PhD studentsScholarshipstudents / 
Interns / ContractorsResearchfellows / 
Attendees / HonoraryFellowsVisitors / 
Post-graduatetraining / Studentsattendingspecializationschools

Other Hiringdate/employmentstartdate Employmentenddate Part time NO  YES  %

Detaileddescriptionof workactivitiesundertaken:

Researchtopicandrelatedresponsibleperson:

Theworkactivity involvesdriving aservicevehicle: NOYES

If yes,specify thetype:_

1.INFORMATIONAND TRAINING,HEALTHMONITORING

TrainingasexArt. 37of LegislativeDecree81/08andsubsequentadditions andamendments, State-RegionsAgreementof21/12/2011

Certificatesattached:NOYES

Healthmonitoring:

Judgement ofsuitability asexArt.41ofLegislativeDecree81/08andsubsequentamendments andadditionsNOYES

If yes: attachthecopyof thejudgementof suitability

NOTES:_

2.USE OFDISPLAY SCREEN EQUIPMENT

Use ofdisplayscreen equipmentNOYES

Besides computerwork,whichotheractivitiesareregularlycarriedout?

3.MANUALHANDLING OF LOADS

The activity involvesthemanual handlingof loads

NOYESup to Kg

Operatingprocedures:

Weeklyfrequency: There are liftingdevices NO  YES 

4.USE OFWORK EQUIPMENT (machinetools,plants,forklift trucks,bridgecranes,etc.)

NOYES

Specify which:

WeldingactivitiesarecarriedoutNOYES

If yes,specify thetypeofwelding:

5.USE OFCHEMICALSUBSTANCES (SEE TABLEAand B)

Activity Operatingprocedures(e.g.:under a fumehood,in a ventilatedroom,etc.):

Supplementwith theattached form

Agent / Physicalstate(1) / Hazardclass(2) / CASNo.
(chemicalabstractservice) / Risk Phrase(3) / Handlingquantity(4) / Handlingfrequency
Frequency(5) / Duration(6)

(1)) Substance’sphysicalstate:G= gas; A=aerosol; L =liquid; S=solid; P= powder.

(2)Hazardclass: T,Xn,Xi,etc.

(3)Risk phrase:seethesafety datasheets

(4)) Specify theminimumand/ormaximumusagequantity foreachindividualoperation.

(5)) Frequency:d =daily; w= weekly; m=monthly; o =other(specify)

(6)Duration: specify thedurationofthesubstance’shandlingoperatione.g.:afewseconds, afewminutes, 15minutes, etc.

ExposuretocarcinogenicagentsNOYES

Ifyes,supplementwith theattachedform

6.EXPOSURE TOBIOLOGICAL AGENTS (ANNEX XLVI of Legislative Decree81/08andsubsequentadditionsandamendments)

The activity involvesexposureto biologicalagentsNOYES

Agent / Riskclass / Exposure / Specify thehandlingquantity andfrequency,andany notes
2 / 3 / 4 / Direct(*) / Indirect(**)

(*)Direct exposuremeans thatdue tothedeliberateanddirectuse ofthebiologicalagent (e.g. HIVhandling)

(**) Indirectexposure means thatcausedbythepotentialpresenceofthebiologicalagent inthematerialhandled(e.g.handling ofbiologicalliquids)

Operatingprocedures(shortdescription)

7.EXPOSURE TO IONISING RADIATION(X-rays)

The activity involvesexposureto ionisingradiationNOYES

Operatingprocedures(shortdescription)

8.EXPOSURE TO NON-IONISING RADIATION

The activity involvesexposureto:

Microwaves / NO / YES / Frequencyemitterdevice
Radio frequencies / NO / YES / Frequencyemitterdevice
Laser / NO / YES / Class
Ultraviolet / NO / YES / Wavelength
Infrared / NO / YES / Frequencyapplicatortype
Ultrasound / NO / YES / 

Other(specify):

9.EXPOSURE TOOTHER PHYSICALAGENTS

The activity involvesexposureto:

noise / NO / YES / 
Vibrations / NO / YES / 

If yes,specify theexposurelimit valuesrespectivelyLEX=dB(A)and Ppeak=Pa (140dB(C), referencedto 20μPa)

VibrationsNOYES

If “yes”

a)for hand-arm systemvibrations:

thedailyexposure limitvalueover 8 hoursism/s2;overshortperiodsis_ m/s2;

thedailyactionvalueover8hoursis_m/s2.

b)for whole-bodyvibrations:

thedailyexposure limitvalueover 8 hoursis_m/s2;overshortperiodsism/s2;

thedailyactionvalueover8hoursism/s2.

Notes:

10.ACTIVITIES IN SPECIALCONDITIONS

The activity involvesexposureto:

Cryogenic liquidsNO YES Specify which Finedustor fibres NO  YES Specify which The roomisequippedwith a dustaspirationsystem NO  YES 

System characteristics:

With animals / NO / YES / 
Outside / NO / YES / 
In coldrooms / NO / YES / 

Other(specify):

11.SUPPLYOFPERSONAL PROTECTIVE EQUIPMENT ANDWORKCLOTHING

Overalls / Labcoat
Safety helmet / Hearingprotectiondevices(Plugs / Muffs)
Safety glasses / Safety shoes
Faceshields / Dustmasks

Solvent,smokeand mistmasksProtectivegloves againstmechanicalattack

Protectivegloves againstchemicalattackProtectivecreams/ointments

Fallprotectionequipment(specify which:)

Protectiveclothingagainstchemicalattack

Other(specify)

EducationabouttheuseofPPE / NO / YES / 
Trainingin theuseof PPE / NO / YES / 

ADDITIONALNOTES:_

Date ofcompletion: Signatureof theworker

Signatureof the Personin charge/ Headof laboratoryteaching andresearchactivity (asexArt.5 of MinisterialDecree363/98)

Signatureof the Manager

UNIVERSITÀDEGLISTUDI DI BRESCIASERVIZIODIPREVENZIONEEPROTEZIONE

AGENTECHIMICO / caratteristichefisiche ediaggregazione(1 ) / modalitàdiimpiego(2) / codiceCAS / tipo disostanza(es.
Infiammabile, tossico,nocivo,etc.) / frasidirischio(R) / Quantitàutilizzatapersingolaoperazione(specificare unitàdimisura) / Frequenzadiutilizzo:
n°volte/Ssettimanan°volte/Mmese
n°volte/A
anno / Dispositividiprotezioneutilizzati
(3) / Vieneutilizzatacappaaspirante
SiNo

UNIVERSITÀDEGLISTUDI DI BRESCIASERVIZIODIPREVENZIONEEPROTEZIONE

AGENTE
(specificarelaconcentrazione) / caratteristichefisiche ediaggregazione
 / R 45 / R 49 / R 46 / R 47 / R 40 / Quantitàutilizzatapersingolaoperazione(specificareunitàdimisura) / Frequenzadiutilizzo:
n°volte/Ssettimanan°volte/Mmese
n°volte/A
anno / L’attivitàvienesvoltain sistemachiuso
SiNo / Vieneutilizzatacappaaspirante
SiNo / Èutilizzatocamiceotuta
SiNo / Vengonoutilizzatiguanti
SiNo / Vengonoutilizzatiocchialiovisierediprotezione
SiNo / Èutilizzatamascherina
SiNo / Èutilizzatamaschera afiltroselettivo
SiNo