EMPLOYEE EXPOSURE MEASUREMENT RECORD

Facility:                                                                                     Area:                                                               

Sampled by:                                                                              Date:                                                               

Temperature:                                                                            Altitude:                                                           

Sample #:                                  Employee Name:                                               SS#                                         

Operation(s) Monitored:                                                                                                                                    

Type of Sample:  Personal                                 Breathing Zone                         Area                                        

Operating conditions and control methods:                                                                                                          

Time on:                                                                       Time off:                                                                      

Elapsed time (minutes)                           Indicated flow rate (LPM)                     Volume (liters)                         

Calibration location:                                           by:                                            Date:                                       

Sampling/analytical method:                                                                                                                               

Evidence of accuracy:                                                                                                                                      

Remarks, possible interferences, action taken, etc.:                                                                                             

Results of sampling analysis or instrument reading:                                                                                             

Exposure of employee (indicate 8-hr average or 15 min) and sample numbers it is based on: