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Reproductive and Developmental
Health Hazard Questionnaire

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4 A. Agents used at work (click to expand / collapse)

List materials you are currently using or anticipate that you might use during preconception period or pregnancy 1) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   2) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   3) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   4) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   5) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   6) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   7) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   8) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   9) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   10) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   11) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   12) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   13) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   14) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:   15) Agent Name: Agent Type: chemical biologic radiation or noise Frequency and Duration of use (e.g. once per day for 2 hrs) per hour day week month year for how long: Physical State of Agent: solid liquid gas Quantity used per unit of time (e.g. 10 ml per week) per hour day week month year Protective Equipment Location fume hood bench other If "Other", please describe:

B. Do you have any specific health or safety concerns about your work? If so, describe:

C. Do you store or consume food or beverages in your workplace?

Yes No

D. What type of personal protective equipment do you wear while working?
Gloves	Respirator
Lab Coat / Apron	Hearing Protection
Dust Mask	Other (list):
Eye / Face Protection

E. Have you had any spills or unintentional exposures recently? If so, describe:

F. Laboratory Environment: (if applicable)

(1) How much of your time do you spend doing: Bench work % Office work %

(2) Are other people working in the same lab room as you? Yes No

(3) Does your hood have enough room in it? Yes No

(4) Describe how chemicals are stored in your lab:

When you have completed this questionnaire,
please select whom you'd like to submit it to:
* Select one of the following: Mary Dougherty Russell Furr Yong Kim Nancy Young

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