DOSH Carcinogen Reporting (183A)

REPORT OF USE
OF REGULATED CARCINOGENS

Title 8 California Code of Regulations section 5203 requires reporting the use of regulated carcinogens to the Division of Occupational Safety and Health. The list below indicates those carcinogens currently regulated and references the appropriate Title 8 Section numbers (in bold) for each regulated carcinogen. Completion of the information below meets these requirements for Report of Use.

Any change in location, use, additions, or deletions of carcinogens used in your workplace, must be reported within 15 calendar days.

A copy of each written report required by the section is required to be posted in the locations where the carcinogens are present in the workplace or in another appropriate location where the posting is conspicuous to employees.

Employer/Company Information *This question is required.

Employer/Company and Division Name
Telephone Number
Address
City
Zip

County *This question is required.

If there has been a change, write the previous name; address; date, & report number if known

Contact Person (person completing this form) *This question is required.

First Name:
Last Name:
Title:
Telephone Number:
Email Address:

Original Signature *This question is required.

Clear

Signature of

DOSH Carcinogen Reporting (183A) - PIPED

Report of Use of Regulated Carcinogens