Fillable Printable Industrial Hygiene Program Evaluation
Fillable Printable Industrial Hygiene Program Evaluation
Industrial Hygiene Program Evaluation
DA FORM 7693, APR 2013
PREVIOUS EDITIONS ARE OBSOLETE.
INDUSTRIAL HYGIENE PROGRAM EVALUATION
For use of this form, see DA PAM 40-503; the proponent agency is the Office of The Surgeon General.
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(YYYYMMDD)
ORGANIZATION DATE
Yes No N/A
RESOURCES: PERSONNEL/BUDGET/EQUIPMENT
Do all industrial hygiene program (IHP) staff have current and comprehensive individual development
plans (IDPs)?
1.
Does the industrial hygiene program manager (IHPM) ensure equipment is calibrated according to Army
Regulation (AR) 750-43?
2.
Does the IHPM ensure calibration records are maintained according to AR 25-400-2?
3.
Is there a prioritized budget plan for annual staffing, equipment, supplies and costs?
4.
Does the IHP use accredited laboratories for sample submission?
5.
Is there adequate office space, storage space, and laboratory space and adequate transportation for the
IHP?
6.
BUSINESS PRACTICES/DOCUMENTATION
Does the IHP use the Department of Defense (DOD) Industrial Hygiene Exposure Assessment Model as
the business practice?
7.
Are standing operating procedures (SOPs) developed for specific industrial hygiene (IH) practices such
as equipment calibration?
8.
Are all survey and IH hazard data entered into the Defense Occupational and Environmental Health
Readiness System-Industrial Hygiene (DOEHRS-IH)?
9.
Does the IHP use the DOEHRS-IH master schedule?
10.
Is there a system developed to track and document Department of the Army-required activities and IHP
support activities not available in DOEHRS-IH (for example, mandatory training, meetings, design
reviews, command requests, etc.)?
11.
Are written reports of sampling results, survey information and recommendations to customers reviewed
by the IHPM?
12.
Is there an IHP action plan submitted to the chief of preventive medicine or his or her equivalent for
review?
13.
Does the IHP perform design reviews according to applicable regulations?
14.
Does the IHP verify ventilation survey data in DOEHRS-IH?
15.
Does the IHP ensure DOEHRS-IH data are complete and support accurate metrics for the Army Med-
ical Department Command Management System (CMS) and the Assistant Chief of Staff for Installation
Management Installation Status Report (ISR)?
16.
Does the IHP perform workplace surveys as scheduled through the master schedule?
17.
Does the IHP document and make recommendations for engineering and administrative controls and
personal protective equipment (PPE)?
18.
Does the IHP perform qualitative and/or quantitative IH assessments?
19.
Does the IHP follow chain-of-custody procedures for sample submission according to U.S. Army Public
Health Command (USAPHC) Technical Guide (TG) 141?
Are IH records secured according to applicable laws/regulations?
20.
21.
HEARING PROGRAM
Does the IHP survey all known and suspected noise-hazardous areas at least once and within 30 days of
any change in operation?
22.
Does the IHP conduct noise sampling and determine time-weighted average (TWA) for workers?
23.
Does the IHP maintain a current inventory of all noise-hazardous areas in DOEHRS-IH?
24.
Does the IHP establish noise contours where appropriate and feasible?
25.
VISION CONSERVATION
Does the IHP assess and document eye hazards and eye protection required and used?
26.
ERGONOMICS
Does the IHP identify ergonomic hazards during IH surveys?
27.
Does the IHP perform or assist with ergonomic evaluations?
28.
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OCCUPATIONAL RADATION PROTECTION
Does the IHP identify ionizing and nonionizing radiation health hazards during worksite evaluations?
29.
MEDICAL TREATMENT FACILITIES
Does the IHP participate in medical treatment facility (MTF) hazard vulnerability analyses?
30.
Does the IHP conduct ventilation system assessments in specialty areas (operating rooms, isolation
rooms, laboratories, pharmacies, etc.)?
HAZARD COMMUNICATION
For the hazard communication (HAZCOM) program, does the IHP identify training requirements by re-
viewing workplace evaluations?
32.
31.
Does the IHP assist in developing and providing HAZCOM training?
33.
Does the IHP ensure chemical inventories comply with HAZCOM requirements?
34.
Does the IHP review and interpret material safety data sheets (MSDSs)?
35.
RESPIRATORY PROTECTION PROGRAM
Does the IHP evaluate workplaces to determine respiratory protection requirements?
36.
37.
PPE (OTHER THAN RESPIRATORY PROTECTION)
Does the IHP evaluate workplaces to determine if workers require PPE, other than respiratory protec-
tion, and recommend types of PPE based on assessment of the workplace hazards?
38.
HAZARDOUS AND MEDICAL WASTES
Does the IHP identify locations (shops), processes, and personnel involved in the handling and storage of
hazardous, pharmaceutical, and medical wastes?
39.
Does the IHP provide training to employees on proper work practices and PPE needed to reduce poten-
tial exposure to hazardous and medical wastes?
40.
Does the IHP review site safety and health plans for hazardous waste remediation projects?
41.
Does the IHP staff assist the environmental science officer (or equivalent) by reviewing SOPs regarding
safe handling and storage practices?
42.
Does the IHP ensure training is provided to those workers included in the respiratory protection
program?
INDOOR AIR QUALITY AND INDOOR ENVIRONMENTAL QUALITY
Does the IHP prioritize evaluation of operations where there is the potential for nonindustrial indoor en-
vironmental problems?
43.
Does the IHP determine if there are feasible solutions to resolve indoor environmental quality (IEQ)
problems to prevent them from recurring?
44.
Does the IHP coordinate with the engineering division to conduct design reviews to evaluate existing
ventilation systems and to recommend improvements?
45.
Does the IHP coordinate with the Directorate of Public Works (DPW)/Directorate of Installation
Operations (DIO) or the building facility management offices to correct any building or ventilation
deficiencies?
46.
47.
CONFINED SPACE ENTRY
Does the IHP assist with identifying confined spaces and maintain a list of confined spaces?
48.
49.
Does the IHP assist in the selection of respiratory protection equipment and other PPE for confined
space operations?
50.
Has the IHP established a professional collaboration among safety, DPW, and the fire department to en-
sure the local confined space regulation meets Occupational Safety and Health Administration require-
ments?
51.
CONTRACTING OFFICE
Does the IHP perform inspections of construction, renovation and abatement projects to ensure regula-
tory compliance?
52.
Does the IHP consult American National Standards Institute (ANSI)/American Society of Heating,
Refrigerating and Air-Conditioning Engineers (ASHRAE) Standards 55 and 62 for specific assessment
guidance, ANSI/ASHRAE/American Society for Healthcare Engineering (ASHE) 170 for guidance spe-
cific to healthcare facilities, and U.S. Army Center for Health Promotion and Preventive Medicine
(USACHPPM) TG 277, USACHPPM TG 278, ANSI/Institute of Inspection, Cleaning and Restoration
Certification (IICRC) S500 and ANSI/IICRC S520 for guidance specific to water damage restoration and
mold assessment and remediation?
Yes No N/A
Does the IHP review the confined space program annually?
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DA FORM 7693, APR 2013
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IH PROGRAM ASSESSMENT
Does the IHPM perform an annual assessment of the IHP?
53.
Are the results of the annual assessment sent to the medical commander and to USAPHC/Army Institute
of Public Health (AIPH) for inclusion in the overall Army IHP improvement initiatives?
54.
Does the IHP participate in external audits to document program effectiveness and make improvements
to the IHP?
55.
RELATIONSHIPS
Does the IHP conduct joint worksite visits with occupational health (OH)?
56.
57.
Does the IHP conduct joint worksite visits with occupational medicine personnel to address worksite
causes of elevated exposures?
OCCUPATIONAL MEDICINE
HEARING PROGRAM
Does the IHP provide, upon request, the names and work locations of noise-exposed and ototoxic-
exposed personnel to the local hearing program manager, the unit commander or supervisor, and the OH
program manager?
58.
VISION CONSERVATION AND READINESS PROGRAM
Does the IHP provide, upon request, the names and work locations of personnel exposed to eye hazards
to the local vision conservation and readiness officer, the unit commander or supervisor, and the OH pro-
gram manager?
59.
ERGONOMICS
Does the IHP participate on the installation ergonomic subcommittee?
60.
MEDICAL TREATMENT FACILITIES
Does the IHP participate on the environment of care committee?
61.
ASBESTOS
Does the IHP participate on a multidisciplinary installation asbestos team?
62.
Does the IHP provide technical advice and review contract specifications/proposals for asbestos
abatement projects?
63.
LEAD
Does the IHP participate in a multidisciplinary installation lead team?
64.
Yes No N/A
Does the IHP provide policy and guidance for lead hazard management programs?
65.
Does the IHP conduct audits to manage in-place lead hazards or lead-contaminated areas of concern?
66.
Does the IHP participate in the Childhood Lead Poisoning Prevention (CLPP) Program?
67.
FEDERAL EMPLOYEES COMPENSATION ACT PROGRAM
Is an IHP staff person a member of the Federal Employees Compensation Act (FECA) working group?
68.
Does an IHP staff person provide data and assistance as needed to the FECA working group?
69.
CHEMICAL SURETY
If applicable as part of the chemical surety program, does the IHP work with the installation chemical
officer to conduct health hazard inventories and hazard exposure assessments involving chemical
operations?
70.
LABORATORY BIOSAFETY
If applicable as part of the laboratory biosafety program, does the IHP serve on the biosafety committee?
71.
As part of the laboratory biosafety program, does the IHP assist with the risk assessment process?
72.
Does the IHP perform annual laboratory inspections?
73.
COMMANDERS
Does the IHP inform the medical/installation commander of the staff duties, abilities and
accomplishments of the IHP?
74.
Does the IHP inform the commander of the value and cost effectiveness of the IHP?
75.
SAFETY OFFICE
76.
Does the IHP coordinate with the safety office to ensure IH recommendations for abatement or control
of health hazards are implemented, and, if not implemented, then included in the formal installation
hazard abatement plan?
Does the IHP coordinate with the safety office to ensure all worksites are inspected according to the
Standard Army Safety and Occupational Health Inspection (SASOHI) program?
77.
DA FORM 7693, APR 2013
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PREVIOUS EDITIONS ARE OBSOLETE.
Page 4 of 4
SAFETY AND OCCUPATIONAL HEALTH ADVISORY COUNCIL
Is an IHP staff person a member of the Safety and Occupational Health Advisory Council (SOHAC)?
78.
Yes No N/A
Does the IHP provide suggestions/recommendations to the SOHAC?
79.
PUBLIC AFFAIRS OFFICE
Does the IHP coordinate with the public affairs office to promote the IHP?
80.
DIRECTORATE OF PUBLIC WORKS
Does the IHP coordinate with the DPW/U.S. Army Installation Management Command to ensure new and
existing controls, to include ventilation systems, are effectively implemented?
81.
Does the IHP coordinate with DPW to ensure participation in the design review process for proposed
new systems and modifications to existing systems?
82.
ENVIRONMENTAL COORDINATOR
Does the IHP coordinate with the environmental coordinator to ensure IH hazards are identified and
controlled as part of the installation environmental programs?
83.
INSTALLATION INTEGRATED PEST MANAGEMENT COORDINATOR
Does the IHP coordinate with the installation integrated pest management coordinator to evaluate poten-
tial pesticide exposures?
84.
CIVILIAN PERSONNEL OFFICE
Does the IHP coordinate with the civilian personnel office to assist the IHPM with staffing and specific
requirements for job descriptions?
85.
CONTRACTING OFFICE
Does the IHP coordinate with the contracting office to ensure contractors have compliant occupational
safety and health programs by reviewing installation contracts?
86.
OTHERS
Does the IHP coordinate with applicable unions, work councils, supervisors and workers to ensure health
and safety concerns are addressed and regulatory compliance is accepted at all levels?
87.
EMAIL SIGNATURE DATE
POINT OF CONTACT PHONE
NOTES/REMARKS
(YYYYMMDD)
