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Workbook for Designated Substance Assessments 11 366-BPV-01-IMOT © 2024, Workplace Safety & Prevention Services (WSPS) 1 877 494 WSPS (9777) | 905 614 1400 | WSPS.CA APPLICATION – WORKSHEET 2: IS WORKER EXPOSURE LIKELY? 1. In what form does the substance enter the facility? __________________________________________________ Product title: ____________________________________ Type of container: ____________________________ Size of Container: _________________________________ 2. Is this form altered during use or in the operation? YES NO If YES, indicate altered form: ______________________________________________________________________ 3. Is there a possibility of the substance being released into the workplace environment during normal use? YES NO If YES, indicate the stage of the operation or areas where this can occur. ____________________________________________________________________________________________________ 4. If YES to Question 3, specify the job functions and approximate number of employees who might be exposed: Job Function Number of Employees ___________________________________________________ ____________________________________________ 5. If YES to Question 3, indicate how workers could be exposed (check all that apply): Inhalation Skin absorption Ingestion Skin contact 6. If NO, to Question 3, is there a likelihood of the chemical to escape due to leaks, accidents, etc.? YES NO Are workers likely to be exposed? YES NO Conclusions Are there any activities/situations where exposure by any route is likely? YES NO If NO, no further action is necessary. Date completed: ______________________________________ If YES an assessment is necessary. Proceed to Section III. Note: If protection against exposure has been controlled by engineering controls that can fail or deteriorate for any reason, or to a work/hygiene practice, an assessment is necessary, Proceed to Section III. WSPS.CA