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General Right-to-Know Certification Form

Supervisors must provide detailed information on the hazardous materials used or stored in their work area and must include the information stated in the questions noted below. When each employee completes this training program, the supervisor must review the health and physical hazards specific in their workplace.

Employee/Supervisor Responsibility

For verification that you have completed this course and received the required workplace specific information part of this training:

Fill out your personal information and answer the seven review questions.
Review the specific health and physical hazards in your workplace with your supervisor.
Before submitting the completed form, print a copy for your records and give a copy to your supervisor.

First Name

Last Name

Person #

Department

Building & Room #

Phone

Today is

My Supervisor is

My supervisor provided detailed information on the physical and health hazards of hazardous materials present in my workplace.

My supervisor discussed methods and observations I can use to detect the presence or release of hazardous chemicals (such as employee monitoring, visual appearance or smell).

My supervisor discussed measures I can take to protect myself, including appropriate work practices, emergency procedures and personal protective equipment.

My supervisor informed me of the location of hazard communication materials, records, and lists of any hazardous chemicals.

My supervisor provided instructions on the use and interpretation of labels and MSDS information for hazardous chemicals found in my work area.

My workplace has the appropriate "Hazard Communication" and "Right-to-Know" signs posted.

Why does NYS have a Right to Know Law?

Where would you find a copy of a MSDS?

Where would you get specific information concerning toxic substances in your workplace?

What are two major health hazards associated with hazardous chemicals?

What are ways chemicals can enter the body?

Name at least 2 measures that can be used to protect employees from exposure to chemicals:

Why is reading the label important?