August, 2004 Rev. 1 1Job Safety Assessment Form Department of Chemical Engineering Michigan Technological University Equipment Name: JSA Author: Room Number/Building: Faculty Supervisor: Revision #: Revision Date: Purpose of Experiment / Equipment: Briefly describe what this experiment is designed to achieve and the types of data collected. Personal Protective Equipment (PPE) – Check all PPE worn during the entireexperiment. Do not list these in the procedure section. Long PantsSafety GlassesHard HatApronLong SleevesSplash GogglesInsulated GlovesEar ProtectionNon-porous ShoesFace ShieldChemical GlovesOther: Hazard Summary– Check all general hazards that are likely to be encountered during this experiment and list the major source of the hazard.Hazard Major Source of Hazard ToxicityFire/FlammabilityReactivityPressure HazardElectrical ShockMechanical HazardHot Surfaces/ High Temp > 150 F Biohazard Laser Radiation Ionizing radiation Other: Other: Expected Operating Conditions – Temperature Pressure Normal: Normal: Minimum: Minimum: Maximum: Maximum:
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