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Facility Name:Name of Exposed Worker:Last Name:First Name:ID#Date of Exposure:/ /Time of Exposure::? AM ? PM Job Title / Occupation:Dept/Work Unit:Location Where Exposure Occurred:Name of Person Completing
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The name of the exposed worker is not provided.
The employer or person in charge of the workplace is required to file the form.
The form can be filled out electronically or by hand, providing all necessary information about the exposed worker.
The purpose is to report and track exposure of workers to certain hazards in the workplace.
Information such as name of worker, type of exposure, duration, and measures taken to protect the worker.
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