Appendix C

San Juan College

Hazard Communication Plan

Employee Training Record for____________________________

(To be kept in workplace)

Date:_________________________

Name:__________________________________________________________________________

SSN:________________________ Position:____________________________________________

Department:________________ Work Group:___________________________________________

Supervisor:______________________________________________________________________

I have received training on the General Hazard Communication (HAZCOM) Plan for San Juan College and site specific Hazard Communication training for my work area.

I understand the following;

1.     I must be trained regarding hazardous chemicals in my work area, upon my initial assignment to the work area, whenever work procedures are changed concerning the hazardous chemicals in the work area, or a new chemical is introduced to work area.

2.     It is my responsibility to understand the characteristics and physical and health hazards associated with the hazardous chemicals in the work area.

3.     I understand that Material Safety Data Sheets will be made available to me, upon request, for each chemical to which I may be exposed in the work area.

4.     I understand that I will have access to the San Juan College Hazard Communication Plan for my work area.

I have received instruction on the General HAZCOM Plan and the site-specific HAZCOM plan with attached chemical inventory for Room(s)___________ , Building___________ .  I acknowledge that I have been instructed in the following areas concerning the inventoried hazardous chemicals to which I maybe exposed.

1.     The chemical and common name of the inventoried hazardous chemical.

2.     The location and operation, in the work area, involving hazardous chemicals.

3.     The location of the HAZCOM plan, MSDS book, and chemical inventory.

4.     The proper and safe handling procedures for the inventoried hazardous chemicals.

5.     The physical and health hazards of the inventoried chemicals in the work area.

6.     Methods to protect myself and co-workers from exposure to hazardous chemicals

7.     Emergency procedures for the work area.

8.     An explanation of the chemical labeling system.

9.     How to obtain and use hazard information.

__________________________________          _________________________

                   Signature of Employee                                          Date

__________________________________         _________________________

                   Signature of Supervisor                                        Date

Gary Lee
Director of Environmental Health
4601 College Blvd.
Farmington, NM  87401
(505) 566-3063 or (505) 566-3190