Appendix F - Appendix F to Subpart C of 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.

(signature of worker) (printed name of worker) (date signed by worker)