Falmouth Exeter Plus
COSHH Assessment Request Questionnaire (CARQ) Form
Please ensure that you submit a Safety Data Sheet (SDS) with this CARQ form as a COSHH assessment
cannot be produced without this information. The SDS must be obtained from the manufacturer of the
product and not from a supplier of a similar product.
Name: (of person completing this
form)
Location: (where the product is used)
Product Name: (Exact product name
as stated on label – including any part
or ref number)
Manufacturer’s or supplier’s name
and address: (Must be a UK address.
Include any postcodes and telephone
and/or fax numbers where possible)
Product Description:
(For example, is the chemical an
abrasive, acid, activator, ceramic,
release agent, sealant, degreaser,
surfactant, primer, thinner, resin,
asphalt, binder, catalyst, bonding
agent, fixative etc.)
Please state if the substance is
released during the work process as an
airborne contaminant, i.e. dust, fumes,
mist, fibres, vapour, gas.
How much of the material is used
in one working day?
Frequency of use?
Daily
Weekly
How long is material in use during
the day? (max amount used in one
day)
Yearly
(Hours, approx.)
Outside
Where is the material used?
Monthly
Inside Poorly
Ventilated
Inside Well
Ventilated
Confined
Space
Other (please describe)
FX Plus CARQ Form (February 2014)
COSHH Assessment Request Questionnaire (CARQ) Form
Page 1
How many people are directly
exposed?
Is the material being used outside
of normal temperature range?
Are there any susceptible workers?
If ‘Yes’ please indicate:
Are any other people exposed?
Yes
No
Yes
Elderly
Pregnant
No
Young
Disabled
Yes
No
Yes
No
Medium
Amount used
If ‘Yes’, how are they exposed?
Is the product being mixed with
another medium?
If ‘Yes’ please indicate:
Additional Work Practice
Information:
(Describe in as much detail as possible
how the product is used and if a
specific tool is used during the process.
For example, cutting (hand), dabbing,
spreading, spraying, pouring, brushing,
diluting, mixing, hand applying, gun
applying, automated application,
machining etc.)
Existing Control Measures:
Where Personal Protective Equipment
is currently in use please specify the
BS EN, BS ISO or BS EN ISO standards
for the PPE i.e. EN 374-1:2003 Protective gloves against chemicals and
micro-organisms.
Signed
Dated:
Please send the completed CARQ form with SDS to:
[email protected]
or
No.8 Tremough Barton Cottage, Penryn Campus, Penryn, TR10 9FE
FX Plus CARQ Form (February 2014)
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