I. COMPANY-SPECIFIC INFORMATION
Company Name:
Company Address (for facility under study):
Site Visit Dates:
Information related to use of carbon nanotubes (CNT) or carbon nanofibers (CNF)
Primary manufacturer of: Secondary manufacturer of:
CNT or CNF material #1:
Synthesis method, if a primary manufacturer:
Precursor & catalyst used, if a primary manufacturer:
CNT or CNF source, if a secondary manufacturer:
Nominal aspect ratio: Measured in bulk material
Reported by company
Chemicals used in purification:
CNT or CNF material #2:
Synthesis method, if a primary manufacturer:
Precursor & catalyst used, if a primary manufacturer:
CNT or CNF source, if a secondary manufacturer:
Nominal aspect ratio: Measured in bulk material
Reported by company
Chemicals used in purification:
CNT or CNF material #3:
Synthesis method, if a primary manufacturer:
Precursor & catalyst used, if a primary manufacturer:
CNT or CNF source, if a secondary manufacturer:
Nominal aspect ratio: Measured in bulk material
Reported by company
Chemicals used in purification:
Other chemical or physical agents used at the facility:
Cleaning operations:
Waste disposal practices:
Personal protective equipment required:
Engineering and administrative exposure control devices and methods:
Other relevant information:
II. WORKER-SPECIFIC INFORMATION (to be completed for every participant in the exposure assessment study)
NIOSH_ID:
Length of shift (observed):
Time spent per shift working directly with CNT or CNF (observed):
Time spent per shift potentially indirectly exposed to CNT or CNF (observed):
Processes and tasks performed by employee:
Task #1: Description:
Date: Time:
Monitored by NIOSH? (Yes/No)
If no, NIOSH_ID of employee performing similar task who was monitored:
Form of CNT and CNF used (e.g., dry powder or liquid emulsion):
Personal protective equipment used:
Engineering controls used:
Other potentially relevant information:
Task #2: Description:
Date: Time:
Monitored by NIOSH? (Yes/No)
If no, NIOSH_ID of employee performing similar task who was monitored:
Form of CNT and CNF used (e.g., dry powder or liquid emulsion):
Personal protective equipment used:
Engineering controls used:
Other potentially relevant information:
Task #3: Description:
Date: Time:
Monitored by NIOSH? (Yes/No)
If no, NIOSH_ID of employee performing similar task who was monitored:
Form of CNT and CNF used (e.g., dry powder or liquid emulsion):
Personal protective equipment used:
Engineering controls used:
Other potentially relevant information:
Task #4: Description:
Date: Time:
Monitored by NIOSH? (Yes/No)
If no, NIOSH_ID of employee performing similar task who was monitored:
Form of CNT and CNF used (e.g., dry powder or liquid emulsion):
Personal protective equipment used:
Engineering controls used:
Other potentially relevant information:
(use additional sheets as necessary)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |