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: _____________________________________________