2._N3B-Form-2061_Beryllium_Hazard_Assessment_Form__DRAFT.pdf

N3B-Form-2061

Beryllium Hazard Assessment Form

Beryllium Area/Operation Description FOD: TA: Bldg.: Room(s):

Other: Inventory Rec ID (if known):

Area/Operation/Activity Description (DO NOT enter any classified information) (only a brief description is needed if detailed document is attached; attach additional pages as needed):

Hazard Assessment Documentation (Reference or attach as necessary) QEA #s:

Sampling Survey ID #s or other sampling data:

Integrated Work Documents (if known):

Other documents (Procedures, statistical analysis, report, memos, email, etc.):

Identification of Beryllium Hazards (Check those that apply; see instructions)

Operation within scope of CBDPP? Yes No

Beryllium Type: Metal Oxide Alloy Salt Other: ______________________

Beryllium Form: Solid Powder/Dust Suspension Ceramic Solution Other: _________

Exposure Route: Inhalation Dermal Contamination Spread Other: ______________________

Frequency: Daily Weekly Monthly Quarterly Annually Variable

Duration: < ½ hr ½ to 2 hrs 2 to 6 hrs 6 to 8 hrs > 8 hrs Variable Beryllium Hazard Comments (Describe variable frequency/duration):

Other Associated Hazards (Describe briefly as appropriate):

Review of Relevant Sampling Data (Reference data in Hazard Assessment Documentation section) Type of sampling data available: Surface Wipes Breathing Zone (BZ) Area Air Bulk None Any air sample results ≥ action level? Yes No Any surface wipe result ≥ trigger levels? Yes No

Comment on Existing Data: DRAFT

RFP-0000297

Controls (Only brief description needed) Engineering:

Hood/LEV #s:

Administrative:

PPE:

Designated Beryllium Area Posting Requirements (Temporary postings may be addressed in “comments” box) Designated Beryllium Area Posting Not Required Beryllium Storage Area Accessible Beryllium Contamination Area Inaccessible Beryllium Contamination Area Airborne Beryllium Area Regulated Beryllium Area See Comments (page 3) Designated Installed Beryllium Containing Materials (Describe):

Other Specified Hazard Description/Warning Signs (Describe):

Anticipated Worker Status (Check all applicable; IWD or beryllium work permit may supersede) Beryllium Worker

Beryllium Awareness Level Worker

General Worker (airborne beryllium or contact with beryllium contamination not expected) Training Comments (Indicate if status varies by work group or task, e.g., adjacent workers):

Sampling Requirements (Complete section for each required sampling type; justify in comments section if sampling is not required) Personal BZ Samples: Not Required Required

Each Time Annual Semiannual Quarterly Monthly Other: _____________ Each Worker Must be Sampled Representative Samples Acceptable; Minimum Number:

Area Air Samples: Not Required Required Standard (2 to 4 lpm) High-Vol (≥ 10 lpm) Each Time Annual Semiannual Quarterly Monthly Other: _____________

Sampling Locations (include sampling in adjacent areas):

Surface Wipe Samples: Not Required Required Minimum # per sampling event:

Each Time Annual Semiannual Quarterly Monthly Other: _____________

Sampling Locations (include sampling in adjacent areas):

Other Samples:

Not Required Required, Describe (e.g., bulk, waste water):

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Type of Sampling Plan Required Simple (i.e., Sampling requirements section above is adequate, applicable comments below)

Integrated Formal: See sampling notes/strategy See below See attached (Check all applicable)

Separate Formal ( IWD, procedure) Document Number(s): ____________________________________

Purpose of Plan: Initial Assessment Ongoing Assessment Area Release Other (describe below)

Comments/Sampling Plan Description (Attach additional pages as needed)

Qualified Industrial Hygiene and Safety Professional (QIHSP) Name Z No. Org. Phone

Completion/Submission:

Person completing form must sign below (Electronic signature preferred), then submit to N3B Beryllium Program Lead Name Z Number Org.

Signature Date

Instructions for Completing the Beryllium Hazard Assessment Form

Note: This form is be completed by (or under the direction of) a Qualified Industrial Hygiene and Safety Professional (QIHSP) and meets requirements for documentation of a Beryllium Hazard Assessment (BHA) specified in N3B’s Chronic Beryllium Disease Prevention Program

(CBDPP).

1. Beryllium Area/Operation Description – Enter location information for the operation or area, including applicable Facility Operations Director (FOD), Technical Area (TA), Building, and Room. Use “Other” to describe outdoor locations or other location specific details. If the operation or area is moveable (e.g., a test vessel), provide details in the comment section.

Inventory Rec ID – If known, enter the beryllium inventory record ID number.

2. Hazard Assessment Documentation – This section identifies the associated exposure assessment and sampling survey ID numbers (as applicable), and is also used to reference or attach other applicable data and documents used for the hazard assessment.

3. Area/Operation/Activity Description – Enter a description of the area and/or operation. Include enough detail to clearly identify the area or specific operation if more than one is performed in the area. Provide enough detail on tasks and processes so that the source of the hazard is clearly defined. DO NOT enter any classified information.

4. Identification of Beryllium Hazards – Check all applicable boxes to provide details on the beryllium hazard.

Operation within Scope of CBDPP? – Indicate if the operation is within the scope of activities listed in P101-21, Chronic Beryllium Disease Prevention Program. Notify the Beryllium Program Lead if it appears the operation is outside of scope. Only activities within scope are permitted.

Mark “yes” if no beryllium operations are involved.

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Beryllium Type – Identify the type of beryllium involved in the operation. If an alloy or salt indicate the specific alloy (including percent beryllium) or salt in the “Comments on Beryllium Hazards” box.

Beryllium Form – Indicate the physical form of the beryllium. Check all that apply (e.g., machining involves both solid and dust).

Exposure Route – Indicate the exposure route of concern. If “Other,” provide details in comments section.

Frequency and Duration – Indicate a best estimate of the frequency of the operation and the duration of time to perform the operation. It is understood this can be quite variable. For example, a maintenance job may need to be performed annually or only when needed, and may take three days to complete; or a sample may be tested once a week, but the test may only take one hour. Best guess is acceptable, but do make a reasonable effort to estimate. Add comments as needed.

Associated Hazards – Indicate other significant hazards that may be associated with the operation or the area (e.g., radiation, other toxic metals, high explosives, etc.).

5. Review of Relevant Sampling Data – Indicate the type of sampling data available for the hazard assessment. Indicate if any air samples (BZ or area) have exceeded the action level and/or if any surface wipes have exceeded trigger levels. Based on the analysis of data and professional judgment; indicate if the existing sampling data is adequate to characterize the operation. If existing data is inadequate, comment on what additional sampling is needed.

6. Controls – Describe the controls used for the operation. Include hood and/or Local Exhaust Ventilation (LEV) numbers. Comment on any apparent deficiencies in controls. Indicate if controls have been demonstrated or can be expected to be effective. If the answer is no, recommendations for improvements and a follow-up hazard assessment are required.

7. Designated Beryllium Area Posting Requirements – Address any non-temporary postings. If known, recurrent temporary changes to postings should be addressed in the comments box on page 2. See P101-21, Section 3.12, Designated Beryllium Areas, for designated beryllium area definitions and requirements. If the area does not meet the definition of a designated beryllium area, check the box for “Designated Beryllium Area Posting Not Required.” This includes areas meeting the definition of Beryllium Area—Otherwise Inventoried. If designated installed beryllium containing materials are present, check the box, and briefly describe the installed materials. The last checkbox should be used for postings other than the above that are warranted (e.g., gloves required for handling beryllium articles, potential for elevated beryllium in soils).

8. Anticipated Worker Status – Indicate training requirements for the operation. Also indicate if workers in adjacent areas should have beryllium awareness training and/or information on the specific operation.

Note: RLMs must determine specific training requirements for all workers based on applicable requirements, training specified in IWDs, or work permits in accordance with P101-21 supersedes the training specified in this section.

9. Sampling Requirements – For each sampling type (personal, area, swipes, other) indicate if it is required or not required. If no sampling is required, an explanation must be included in the “Notes and Comments” section. For each required sampling type, complete the section for the following:

Personal BZ Samples – Indicate sampling frequency and if every worker must be sampled. If representative sampling is acceptable, indicate the minimum number of samples to be collected (e.g., “one sample per craft” or “two samples per shift”).

Area Air Samples – Indicate sampling frequency and if samples are standard volume (i.e., personal sampling pump used) or high volume samples. Indicate general or specific sampling locations. Attach additional pages or area diagrams as needed.

Surface Wipe Samples – Indicate sampling frequency (minimum annual recommended for Beryllium Storage Areas, designated installed beryllium containing materials, or beryllium-contaminated designated beryllium areas routinely accessed by workers) and minimum number of samples per sampling event or area (e.g., “5 samples on floor”). Indicate general or specific sampling locations. Attach additional pages or area diagrams as needed.

Other Samples – Indicate specifically what other samples are required (e.g., bulk, waste water, stack emissions, etc.).

10. Type of Sampling Plan Required – Indicate the type of sampling plan required. Professional judgment based on the frequency of the operation, the number of workers involved, the size of the area, etc., may be required in making this determination; a formal sampling plan may be required per P101-21. Facilities or organizations may have other governing procedures or documents. “Separate Formal” plans may be subject to revision without the update of this form. Multiple boxes may be selected for “purpose of plan.” See P101-21 29 for further details.

11. Sampling Plan Description/Comments – Provide further comments on simple sampling plans or descriptions of formal sampling plans in this box (attachments and other documents may be referenced as necessary). This box is one option for documenting Integrated Formal sampling plans.

12. QIHSP – Enter identifying information and date the form is completed. A QIHSP is a person who meets the necessary professional level core requirements and beryllium hazard assessment duty area requirements of the Industrial Hygiene and Safety Qualification Standard.

13. Completion/Submission – Enter the name, Z#, organization, signature, and date of person completing the form. This may be completed by a QIHSP or someone working under direction of a QIHSP. The person completing the form is responsible to ensure it is submitted to the Beryllium Program Lead.DRAFT