<<< Back to Section II: Chapter 1: Personal Sampling For Air Contaminants |
Printing Instructions |
OSHA-91A Form
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Directive #: 08-05 (TED 01)
Revised: June 2008
APPENDIX II: 1-8.
FIGURE II: 1-24. FRONT OF COMPLETED AIR SAMPLING WORKSHEET FORM OSHA-91A
Air Sampling Worksheet |
U.S. Department of Labor
Occupational Safety and Health Administration |
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1. Reporting ID
5555555 |
2. Inspection Number
123456789 |
3. Sampling
Number: 497330105 |
4. Establishment Name
J & N Casting |
5. Sampling Date: 06-14-07 |
6. Shipping Date: 06-15-07 |
7. Person Performing Sampling (Signature)
Signature |
8. Print Last Name
RIMA |
9. CSHO ID
Z1234 |
10. Employee (Name, Address, Telephone Number):
(123) 456-7899
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14. Exposure Information
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a. Number:
2
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b. Duration:
3.5 Yrs/ ea
person |
B.J. Albrecht, 850 Lego Road |
c. Frequency: 6hr./day |
Pixar City, CA 99999
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15. Weather Conditions:
Indoors |
16. Photo(s): Y
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11. Job Title:
Brass Squeeze Molder Machine Operator - 12 years |
12. Occupation Code |
17. Pump Checks and Adjustments: 7:30 - ok, 8:30 - ok, 9:30 - ok, 10:30 - ok,
11:30 - ok, 12:30 - ok, 1:30 - ok, 2:30 - ok |
13. PPE (Type and effectiveness):
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Safety glasses and ear plugs, no respirators worn |
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18. Job Description, Operation, Work Location(s), Ventilation, and Controls
Operates glass squeeze molding machine. Fills and compacts sand into mold.
Finished molds
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placed on pouring lines. There are fans but no exhaust ventilation. |
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Cont'd |
19. Pump Number: 10337
Sampling Data
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20. Lab Sample Number |
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21. Sample Submission
Number |
ER300 |
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22. Sample Type |
P |
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23. Sample Media |
MCEF |
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24. Filter/Tube
Number |
ER300 |
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25. Time On/Off |
6:30am |
1:00pm |
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12:30pm |
2:48pm |
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26. Total Time
(in minutes) |
360 |
108 |
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27. Flow Rate
l/min
cc/min
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2.13 |
2.13 |
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28. Volume
(in liters) |
766.8 |
230 |
= 996.8 Total volume |
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29. Net Sample Weight
(in mg) |
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30. Analyze Samples for: |
31. Indicate Which Samples to Induce in TWA, Ceiling, etc. Calculations |
Welding Fume |
T |
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(Lead & Cadmium) |
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32. Interferences and IH Comments to Lab |
33. Supporting Samples |
34. Chain of Custody |
Initials |
Date |
a. Blanks: ER302 |
a. Seals Intact?
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Y N |
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b. Rec'd in Lab |
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b. Bulks |
c. Rec'd by Anal. |
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d. Anal. Completed |
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e. Calc. Checked |
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f. Supr. OK'd |
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Case File Page /
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of |
OSHA-91A (Rev. 1/84) |
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FIGURE II: 1-25. BACK OF AIR SAMPLING WORKSHEET FORM OSHA-91A
Pre-sampling Calibration Records
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35. Pump Mfg. & SN
Gilian 10337 |
36. Voltage Checked?
Yes
No |
37. Location/T & Alt.
I.H. Lab – Area Office |
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38. Flow
Rate Calculations:
2128
2132
2129
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39. Flow rate: 2.13 |
40. Method
Bubble
PR |
41. Initials:
JR |
42.
Date/Time:
06/14/07 –5:30am |
Post-Sampling Calibration Records
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43. Location/T & Alt. |
I.H. Lab – Area Office |
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45. Flow Rate: 2.13 |
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44. Flow Rate Calculations:
2129
2131
2133
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46. Initials: JR |
47. Date/Time: 06/14/07 – 3:35pm |
Sample Weight Calculations:
48. Filter No. |
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49. Final Weight
(mg) |
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50. Initial Weight
(mg) |
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51. Weight
Gained (mg) |
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52. Blank
Adjustment |
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53. Net Sample
Weight (mg) |
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54. Calculations and Notes: |
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APPENDIX II: 1-9.
FIGURE II: 1-26. COMPLETED SOIL SAMPLING WORKSHEET ON A FORM OSHA-91A
Air Sampling Worksheet |
U.S. Department of Labor
Occupational Safety and Health Administration |
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1. Reporting ID
0418300 |
2. Inspection Number
123456789 |
3. Sampling
Number: 914687710 |
4. Establishment Name
Curtis Service, Inc. |
5. Sampling Date: 12-05-07 |
6. Shipping Date: 12-18-07 |
7. Person Performing Sampling (Signature)
Signature |
8. Print Last Name
Cooley |
9. CSHO ID
T1234 |
10. Employee (Name, Address, Telephone Number):
It is at the discretion of the CSHO to fill in Sections 10-13, but it is not
necessary for the SLTC. |
14. Exposure Information
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a. Number:
1
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b. Duration:
3 days |
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c. Frequency: 2-4hr./day |
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15. Weather Conditions:
˜2" of rain night before (12-04-07) |
16. Photo(s): Y
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11. Job Title:
Pipe Install Technician/Welder |
12. Occupation Code |
17. Pump Checks and Adjustments: |
13. PPE (Type and effectiveness):
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Safety glasses and steel toe boots |
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18. Job Description, Operation, Work Location(s), Ventilation, and Controls
In this section, indicate: 1) dimensions of the trench; 2) work being done in
the trench;
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3) type of protective system or lack of it in the trench; 4) where in the trench or spoil
pile |
was the sample taken; and 5) address or location of the trench. |
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Cont'd |
19. Pump Number:
Sampling Data
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20. Lab Sample Number |
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21. Sample Submission
Number |
001 |
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22. Sample Type |
Bulk |
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23. Sample Media |
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24. Filter/Tube
Number |
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25. Time On/Off |
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26. Total Time
(in minutes) |
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27. Flow Rate
l/min
cc/min
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28. Volume
(in liters) |
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29. Net Sample Weight
(in mg) |
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30. Analyze Samples for: |
31. Indicate Which Samples to Induce in TWA, Ceiling, etc. Calculations |
S777 |
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Soil Analysis |
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32. Interferences and IH Comments to Lab |
33. Supporting Samples |
34. Chain of Custody |
Initials |
Date |
a. Blanks: |
a. Seals Intact?
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Y N |
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b. Rec'd in Lab |
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b. Bulks |
c. Rec'd by Anal. |
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d. Anal. Completed |
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e. Calc. Checked |
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f. Supr. OK'd |
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Case File Page /
/
/
of |
OSHA-91A (Rev. 1/84) |
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