Appendix F to Subpart C to Part 197 - Sample Worker Certification Form

Benzene Worker's Certification

I, _____(Name of worker), certify in accordance with 46 CFR 197.530—

(1) That I have had, within the previous twelve months, at least one medical examination in compliance with 46 CFR 197.560 or 29 CFR 1910.1028;

(2) That the physician conducting the latest medical examination in compliance with paragraph (1) of this certification did not recommend that I be excluded from areas where personal exposure may exceed the action level as defined in 46 CFR 197.505;

(3) That all respirators and personal protective clothing and equipment that I will use while on the vessel meet the requirements of 46 CFR 197.550(b) and 197.555(c) or of 29 CFR 1910.1028; and

(4) That all respirators that I will use while on the vessel have been fitted and fit tested in accordance with 46 CFR 197.550 (c) and (d) or with 29 CFR 1910.1028.