Hurricane Sandy Site Assessment Survey Question Title * 1. Your name: Question Title * 2. Date: Question Title * 3. Organization: Question Title * 4. Phone number (including area code): Question Title * 5. Time: Question Title * 6. Location (address and nearest intersection): Question Title * 7. Describe what activity or site you are observing in detail: Question Title * 8. Are there any workers available to speak to, if yes please ask the following: Are there any health hazards they are concerned about? What type of monitoring would be useful? Question Title * 9. Are you (select one): Indoors Outdoors Question Title * 10. Is there visible dust in the air? Yes No If yes, what is the source: Question Title * 11. Are there noticeable odors? Yes No If yes, what is the source (Please describe)? Question Title * 12. Are there wet materials? Yes No Number of square feet: Question Title * 13. Is there visible mold? Yes No Number of square feet: Question Title * 14. Is there standing water? Yes No Number of square feet: Question Title * 15. Are there any generators, heaters, cook stoves, or charcoal grills being used (indoors/outdoors)? Yes No Question Title * 16. If generators, heaters, cook stoves, or charcoal grils are being used, are they: Indoor Outdoor Question Title * 17. Is there visible oil/fuel? Yes No Number of square feet: Question Title * 18. Are there oily sediments? Yes No Unsure Number of square feet: Question Title * 19. Are there visible chemical leaks? Yes No Unsure Number of square feet: Question Title * 20. Are there signs of chemical contamination? Yes No Unsure Number of square feet: Question Title * 21. If there are signs of chemical contamination, please describe: Question Title * 22. Is there decaying organic material? Yes No Unsure Number of square feet: Question Title * 23. Are there trucks running? Yes No Number: Question Title * 24. Are there other engines running? Yes No Number: Question Title * 25. Is there visible haze from combustion? Yes No Source: Question Title * 26. Is there fire or smoke? Yes No Source: Question Title * 27. Is there ongoing demolition of debris? Yes No Desribe debris Question Title * 28. Are there visible friable insulation? Asbestos-like Fiberglass Unsure Question Title * 29. Describe visually what you see that may be important: Question Title * 30. Are there any health symptoms observed? Yes No If yes, how many people? Question Title * 31. Are there health symptoms reported? Yes No If yes, how many people? Question Title * 32. Describe health issues: Question Title * 33. Are the workers paid or volunteer? Paid Volunteers Unsure Question Title * 34. Are workers wearing respirators? Yes No Question Title * 35. If respirators are worn, what type? Unsure Dust mask (no N95 designation, may have 1 or 2 straps, may have nose clip) N95 Filtering face-piece with no valve (may have one or 2 straps, may have nose clip) N95 Filtering face-piece with valve Rubber mask with cartridges Question Title * 36. Have workers been fit tested for the respirators they are currently wearing? Yes No Question Title * 37. Have they received any training or orientation about how to use them? Yes No Question Title * 38. Are workers wearing chemical or dust restraint suits over their work clothes? Yes No Question Title * 39. Are workers wearing boots? Yes No If yes, what type: Question Title * 40. Are workers wearing eye protection? Yes No Question Title * 41. Are workers wearing gloves? Yes No Question Title * 42. Are there decontamination facilities? A hand-washing station Full decontamination station None Other: Question Title * 43. What are the level or worker training? None Hazmat Response Emergency Response Asbestos abatement Lead removal Site specific only Question Title * 44. Noise: Is it too noisy to hear someone more than 3 feet away talking in a normal voice? Yes No Question Title * 45. Other observations related to exposures: Question Title * 46. Are there any other safety hazards not asked? Done