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New Employee Survey

Required for ALL new OPS and USPS employees
PI's PLEASE NOTE:

1) ALL charges for processing of employee enrollment (i.e., FedEx, Gator1Cards) will be incurred by the PI.
2) ALL charges for physical examinations will be incurred by the PI.
3) ALL charges, including travel, related to training will be incurred by the PI.

Supervisor's Name:
 
PI's Name:
 
New Employee Name:
 

General Job Duties:           

Grant/Account paid from:
 

Hourly Wage:   
FTE (USPS only): 

Employment Begin Date:   
Employment End Date:   

Graduate Student?             Yes          No
UF/Milton Student?            Yes          No

Does the employee need a PJC Parking Permit?     Yes          No
Does the employee need an email account?             Yes          No

Supervisor Checklist for HAMS Records
(REQUIRED)

Animal Contact direct exposure to vertebrate animals, animal tissues, body fluids or wastes. COMPLETE ANIMAL CONTACT SURVEY

Asbestos Abatement individuals involved in an abatement effort.

Climbing** focus is not only on leg motion but also hand-over-hand motion such as with climbing ladders but not stairs.

Commercial Driver License* for those required to have a commercial driver license as part of their UF employment.

Frequent reaching above shoulder** includes painting, shelving books, running overhead cable, etc.

Heavy Lifting** 45 pounds and over.

Kneeling** more than 2 hours per day.

Operation of Special Purpose Vehicle** includes industrial or farm equipment.

Pesticide Use* individuals who use pesticides as defined in the Medical Monitoring Program for Pesticide Users.  COMPLETE PESTICIDE USE SURVEY

Repeated Bending** more than 2 hours per day.

Repetitive Pulling and Pushing**.

Respirator Use* for individuals required to wear a respirator on a routine or emergency basis. COMPLETE RESPIRATOR USE SURVEY

Work in Areas of Excessive Noise* noise level defined by OSHA. COMPLETE HEARING CONSERVATION SURVEY

None of these apply to this position.

* = Requires specific health assessment.
** = Requires standard health assessment.

Hearing Conservation Survey for HAMS Records
(Complete only if applicable)

Will the type of hearing protection be ear muffs?          Yes          No
Will the type of hearing protection be foam inserts?     Yes          No
Will the type of hearing protection be molded inserts?  Yes          No

Identify any other type of hearing protection to be used: 

Specify the Noise Reduction Rating (NRR) on the hearing protection packaging:

Briefly describe job duties of this position:        

Specify the FIRST noise source and the length of time the employee will be exposed to it:

Specify the SECOND noise source and the length of time the employee will be exposed to it:

Specify the THIRD noise source and the length of time the employee will be exposed to it:

Pesticide Use Survey for HAMS Records
(Complete only if applicable)

All Users* of Toxicity Class I, II, or III Pesticides (Oral or Dermal Ld5O of less than 2200 Mg/kg as Indicated on MSDS).  Shall Participate in The Medical Monitoring Program For Pesticide Users.

*''Use'' Is Defined as Mixing, Loading, Applying or Otherwise Handling (Except in Original, Unopened Containers) Those Materials (Oral or Dermal Ld5O of Less Than 2200 Mg/kg) With a Frequency of More Than 4 Days Per Calendar Month (Any Part of a Day Counting as One Day) And a Volume of More Than One Pint (16 Fl. Oz) of Mixed Solution or One Pound of Dry Material at Any Single Use.

Does the employee meet the definition of user defined above?
 Yes          No

Will the employee use cholinesterase-inhibiting pesticides?
 Yes          No

If yes, what is the frequency of use:
Regular
Intermittent -Time(s) of year: 
Seasonal - Season(s) of year:
Winter
Spring
Summer
Fall    

Respirator Use Survey for HAMS Records
(Complete only if applicable)

Will the type of respirator be disposable?          Yes          No

Will the type of respirator use cartridges (Non-Powered)?  Yes          No

Will the type of respirator use cartridges (Powered)?         Yes          No

Will the type of respirator be an SCBA?          Yes          No

Identify any other type of respirator to be used:         

Will the type of respirator be supplied-air?       Yes          No

The level of work effort will be:
Light
Moderate
Heavy
Strenuous

Identify the extent of usage:
Daily        
Occasionally (More than 1/week)
Rarely or for Emergency Situations

Specify the length of time of anticipated effort in hours:

Identify chemicals used needing respiratory protection:
Pesticides 
Organics
Metals
Other
Please Specify Other: 

Describe Special Work Considerations (i.e. high places, etc.): 

Animal Contact Survey for HAMS Records
(Complete only if applicable)

Will the exposure be:
Recurrent (Category I) 
Isolated, One-Time, Non-Recurrent (Category II)
Other 
Please Specify Other:

Specify the date of initial animal contact:

Specify the FIRST animal contacted and the frequency of contact:         

Specify the SECOND animal contacted and the frequency of contact:         

Specify the THIRD animal contacted and the frequency of contact: