To: All Department Heads and Supervisors
From: The ABC Company Safety Director
Date: June 1, 2005

Re: Identification of the presence at the ABC Company facility of devices and materials containing mercury

Instructions: ABC Company recognizes that exposure to mercury represents a danger to health. The management of ABC Company is determined to minimize the risks of exposure to ABC Company staff and employees and others at the facility. Accordingly, we are asking all department heads and supervisors to complete the following survey form. The purpose of this form is to enable us to:

1. Identify all devices and materials that contain mercury which are present at the facility; and

2. Ascertain the feasibility of replacing such devices and materials with safer substitutes that don't contain mercury.

A. DEVICES & SUBSTANCES

Put a check in the box next to any listed mercury-containing device or substance that\'s present in your department or work area:

Thermometers

Manometers

Batteries

Paints

Fluorescent light bulbs

Mercury reagents

Wall model, blood pressure units

Floor model, blood pressure units

Esophageal dilators

Other [describe]: _____________________________________

B. RECOMMENDED SUBSTITUTES

List any substitute devices or materials that don't contain mercury that would serve as feasible, cost-effective and available replacement for the device or material that does contain mercury:

Name of device or material: _______________________________

Manufacturer: __________________________________________

Manufacturer Contact Info: ________________________________

Your name: ____________________________________________

Department: ___________________________________________

Date of completion: ______________________________________

Signature: _____________________________________________

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