42 CFR 85.3-1 - Contents of a request for health hazard evaluation.
Each request for health hazard evaluation shall contain:
(a) The requester's name, address, and telephone number, if any.
(b) The name and address of the place of employment where the substance or physical agent is normally found.
(c) The specific process or type of work which is the source of the substance or physical agent, or in which the substance or physical agent is used.
(d) Details of the conditions or circumstances which prompted the request.
(e) A statement, if the requester is not the employer, that the requester is:
(1) An authorized representative or an officer of the organization representing the employees for purposes of collective bargaining; or
(2) An employee of the employer and is authorized by two or more employees employed in the same place of employment to represent them for purposes of these Acts (each such authorization shall be in writing and a copy submitted with the request for health hazard evaluation); or
(3) One of three or less employees employed in the place of employment where the substance or physical agent is normally found.
(f) A statement indicating whether or not the name(s) of the requester or those persons who have authorized the requester to represent them may be revealed to the employer by NIOSH.
(g) The following supplementary information if known to the requester:
(1) Identity of each substance or physical agent involved;
(2) The trade name, chemical name, and manufacturer of each substance involved;
(3) Whether the substance or its container or the source of the physical agent has a warning label; and
(4) The physical form of the substance or physical agent, number of people exposed, length of exposure (hours per day), and occupations of exposed employees.
NIOSH has developed two forms entitled “Request for Health Hazard Evaluation” and “Request for Mining Health Hazard Evaluation” to assist persons in requesting evaluations. The forms are available upon request from the offices listed in § 85.3(a) (1) and (2) or from the Regional Consultant for Occupational Safety and Health in any Regional Office of the Department of Health and Human Services.