| Trainee
Name____________________________ |
| Trainee
Social Security Number: ____________ |
| Trainee
Status: _______ |
| Course
Name: ___________________ |
| Course
Code: ___________________ |
| National
Center Course Number: ___________ |
| Date Course
Completed: ____________________ |
| Performance
Criteria Completed: _____________ |
| Performance Objectives: | ||
| Pass | Fail | |
| Topic 1: Identification | ||
| 1.1 Identify examples of physical hazards and health hazards. | ____ | ____ |
| 1.2 Define the term “routes of entry” and describe three examples. | ____ | ____ |
| 1.3
Identify examples of acute effects and chronic effects of health hazards. |
____ | ____ |
| 1.4
Identify and explain key information provided on Material Safety Data Sheets. |
____ | ____ |
| 1.5
Identify examples of the NFPA fire diamond, HMIS labels, and DOT labels, and explain what is represented by the colors, numbers, text, and symbols on each. |
____ | ____ |
| Topic 2: Protection | ||
| 2.1
Identify examples of air-purifying and air-supplied respirators. |
____ | ____ |
| 2.2
Inspect and fit-test an air-supplied respirator to determine if it is in safe working condition and properly fitted. |
____ | ____ |
| 2.3
Select goggles appropriate for assigned tasks and use them in a safe and effective manner. |
____ | ____ |
| 2.4
Select chemical-resistant clothing appropriate for assigned tasks and use it in a safe and effective manner. |
____ | ____ |
| 2.5
Explain how a chemical’s appearance and odor can indicate a hazardous situation. |
____ | ____ |
| 2.6 Describe general steps for responding to a chemical emergency. | ____ | ____ |
| Performance
Evaluator’s Signature:____________________________ |
| Performance
Evaluator’s Name (Print):____________________________ |
| Date
Completed:____________________________ |