Form Ref.

: F-HSE-053
Form Rev.: 04
COSHH Assessment form
Page: 1 of 2

Product Name(s): COSHH

:‫اﺳم اﻟﻣﻧﺗﺞ‬ ‫دھﺎن ﺑراﯾﻣر‬ Assess. No.: 10
Description of ‫ ﻣﺎدة ﺳﺎﺋﻠﺔ‬:‫اﻟﺣﺎﻟﺔ‬
Assessed By:
Substance: ---------- :‫اﻟﻠون‬ :‫ﻗﯾﻣﮫ ﻣن ﻗﺑل‬
Ahmed Ali
:‫وﺻف اﻟﻣﺎدة‬ -------- :‫اﻟراﺋﺣﺔ‬
Workplace
Exposure Limits:
‫ﺣدود اﻟﺗﻌرض ﻟﮭﺎ ﻓﻲ‬
‫ﻻ ﯾوﺟد‬ Date: :‫اﻟﺗﺎرﯾﺦ‬ 2024
:‫ﻣﻛﺎن اﻟﻌﻣل‬
Risk Phrases: R40
Task/Activity:
:‫اﻟﻧﺷﺎط‬
‫ﻣﺎدة ﻣذﯾﺑﺔ ﻋﻠﻰ اﻟﺑﺎرد‬ Safety S2,S13,S36,S
Phrases: 37,S46
Telephone/
Supplier’s Name Fax No’s:
42262774622
& Address: ‫ﺷرﻛﺔ ﻧﯾﺗر و اوﯾﻠد ﻟﻠﺗورﯾدات‬
:‫اﺳم وﻋﻧوان اﻟﻣوارد‬ MSDS
Yes
Attached:
SUBSTANCE PROPERTIES: :‫ﺧﺻﺎﺋص اﻟﻣﺎدة‬

Flammable/
Dangerous to
Highly
Toxic/ Very the
Flammable Oxidiser Explosive Harmful Irritant Corrosive
Toxic Environment
‫ﻗﺎﺑﻠﯾﺔ اﻹﺷﺗﻌﺎل \ﻋﺎﻟﯾﺔ‬ ‫ﻣوﻛﺳدة‬ ‫ﻣﺗﻔﺟرة‬ ‫ﻣﺿرة‬ ‫ﻣﮭﯾﺟﺔ‬ ‫اﻛﻠﺔ ﻟﻠﺟﻠد‬
‫ﺳﺎﻣﺔ\ﺷدﯾدة اﻟﺳﺎﻣﯾﺔ‬ ‫ﺷدﯾدة اﻟﺧطورة ﻋﻠﻲ‬
‫اﻹﺷﺗﻌﺎل‬
‫اﻟﺑﯾﺋﺔ‬

√ X X X √ √ X X

ROUTE OF EXPOSURE: :‫اﻷﺟزاء اﻟﻣﻌرﺿﺔ ﻟﻼﺻﺎﺑﺔ‬ PERSONS AT RISK: :‫اﻷﺷﺧﺎص اﻟﻣﻌرﺿﯾن ﻟﻠﺧطر‬
Users of
Members
Inhalation the product Visitors
Skin ‫اﻟﺟﻠد‬  Eyes ‫اﻟﻌﯾون‬   of Public 
‫اﻹﺳﺗﻧﺷﺎق‬ ‫اﻟﻣﺳﺗﺧدﻣﯾن‬ ‫اﻟزاﺋرﯾن‬
‫اﻟﻌﺎﻣﺔ‬
‫ﻟﻠﻣﻧﺗﺞ‬
Cuts/
Abrasions Other Young
Ingestion Injection
\‫اﻟﻘطﻊ‬  Workers  Persons
‫اﻹﺑﺗﻼع‬ ‫اﻟﺣﻘن‬
‫اﻟﺳﺣﺎﺟﺎت‬ ‫ﻋﻣﺎل أﺧرﯾن‬ ‫اﻟﺷﺑﺎب‬

PPE REQUIREMENTS: :‫ﻣﮭﻣﺎت اﻟوﻗﺎﯾﺔ اﻟﺷﺧﺻﯾﺔ اﻟﻣطﻠﺑﺔ‬

Other: :‫أﺧرى‬

  
 ‫‪Form Ref.: F-HSE-053‬‬
‫‪Form Rev.: 04‬‬
‫‪COSHH Assessment form‬‬
‫‪Page: 2 of 2‬‬

‫‪ADDITIONAL CONTROL MEASURES:‬‬ ‫إﺟراءات إﺿﺎﻓﯾﺔ ﻟﻠﺗﺣﻛم‪:‬‬

‫‪General Precautions:‬‬ ‫اﻹﺣﺗﯾﺎطﺎت اﻟﻌﺎﻣﺔ‪:‬‬ ‫‪Control Measures:‬‬ ‫اﻹﺟرات اﻟﻣﺗﺧذة ﻟﻠﺗﺣﻛم‪:‬‬

‫‪ ‬اﻟﺗﺄﻛد ﻣن إرﺗداء ﺟﻣﯾﻊ ﻣﮭﻣﺎت اﻟوﻗﺎﯾﺔ اﻟﻣذﻛورة اﻋﻼه وأن ﺟﻣﯾﻊ‬

‫‪ ‬اﻟﺗﺄﻛد ﻣن اﻹﺷراف اﻟﻣﺳﺗﻣر ﻣن ﻗﺑل اﻟﻣﺷرف اﻟﻣﺳؤول‪.‬‬
‫اﻟﻣﺳﺗﺧدﻣﯾن ﻋﻠﻰ ﻋﻠم ﺑﺎﻟﻣﺧﺎطر اﻟﻣﺣﺗﻣﻠﺔ وﺑطرق اﻟﺣﻣﺎﯾﺔ ﻣﻧﮭﺎ‪.‬‬

‫‪First Aid/Hygiene Arrangements:‬‬

‫‪Fire Precautions:‬‬ ‫إﺣﺗﯾﺎطﺎت اﻟﺣﻣﺎﯾﺔ ﻣن اﻟﻠﮭب‪:‬‬
‫اﻹﺳﻌﺎﻓﺎت اﻷوﻟﯾﺔ\ﺗرﺗﯾﺑت اﻟﻧظﺎﻓﺔ‪:‬‬
‫‪ ‬ﻓﻲ ﺣﺎﻟﺔ ﻣﻼﻣﺴﺔ اﻟﺠﻠﺪ ﯾﺠﺐ ﻏﺴﻞ اﻟﺠﺰء اﻟﻤﻠﻤﻮس ﺑﺎﻟﻤﺎء واﻟﺼﺎﺑﻮن‬ ‫‪ ‬ﻏﯿﺮ ﻣﺴﻤﻮح ﺑﺎﻟﺘﺪﺧﯿﻦ ﺑﺠﺎﻧﺐ ھﺬة اﻟﻤﺎدة او ﻣﻤﺎرﺳﺔ اي اﻋﻤﺎل ﺳﺎﺧﻨﺔ‬
‫ﻓﻲ ﺣﺎﻟﺔ ﻣﻼﻣﺴﺔ اﻟﻌﯿﻦ ﯾﺠﺐ ﺗﻌﺮﯾﺾ اﻟﻌﯿﻦ ﻟﻤﺎء ﺟﺎري‬ ‫وﻓﻲ ﺣﺎﻟﺔ ﺣﺪوث اﻟﺤﺮﯾﻚ ﯾﻤﻜﻦ اطﻔﺎءه ﺑﺎﺳﺘﺨﺪام طﻔﺎﯾﺔ اﻟﻜﺮﺑﻮن‬

‫‪LEV Requirements:‬‬ ‫‪Monitoring Requirements:‬‬ ‫ﻣﺗطﻠﺑﺎت اﻟرﻗﺎﺑﺔ‪:‬‬

‫‪ ‬ﺗﺘﻄﻠﺐ اﺷﺮاف اﻋﻠﻲ ﻓﻲ ﺣﺎﻟﺔ اﻻﺳﺘﺨﺪام داﺧﻞ اﻻﻣﺎﻛﻦ اﻟﻤﻐﻠﻤﺔ‬

‫‪ ‬اﻟﺘﺎﻛﺪ ﻣﻦ ان ﻣﻜﺎن اﻟﻌﻤﻞ ﺑﮫ ﺗﮭﻮﯾﺔ ﺟﯿﺪة ﺟﺪا‬ ‫‪ ‬ﺗﺘﻄﻠﺐ اﺷﺮاف اﻋﻠﻲ ﻓﻲ ﺣﺎﻟﺔ اﺳﺘﺨﺪاﻣﮭﺎ ﻣﻦ ﻟﺒﻞ اﺷﺨﺎص ﺻﻐﺎر اﻟﺴﻦ‬
‫أو ﻏﯿﺮ ﻣﺪرﺑﯿﻦ‬

‫‪Transport Arrangements:‬‬ ‫ﻣﺗطﻠﺑﺎت اﻟﻧﻘل‪:‬‬ ‫‪Storage Requirements:‬‬ ‫ﻣﺗطﻠﺑﺎت اﻟﺗﺧزﯾن‪:‬‬

‫ﻻ ﯾوﺟد‬ ‫‪‬‬ ‫‪ ‬ﺗﺨﺰن ﻓﻲ ﻣﻜﺎن ﺟﯿﺪ اﻟﺘﮭﻮﯾﺔ وﺟﺎف وﺑﺎرد‬

‫‪Spillage Procedures:‬‬ ‫اﻹﺟرات ﻓﻲ ﺣﺎﻻت اﻹﻧﺳﻛﺎب‪:‬‬ ‫‪Disposal Requirements:‬‬ ‫ﻣﺗطﻠﺑﺎت اﻟﺗﺧﻠص ﻣﻧﮭﺎ‪:‬‬

‫‪ ‬ﯾﺠﺐ اﻟﺘﻨﻈﯿﻒ ﺑﺎﺳﺘﺨﺪام ﻣﻨﺼﺎت ﻣﺎﺻﺔ ﻟﻠﺴﻮاﺋﻞ وﺣﻔﻈﮭﺎ ﻓﻰ‬ ‫‪ ‬ﯾﺘﻢ اﻟﺘﺨﻠﺺ ﻣﻨﮭﺎ ﻋﻦ طﺮﯾﻚ ﺷﺮﻛﺔ ﻧﻤﻞ ﻣﺨﻠﻔﺎت ﺧﺎﺻﺔ وﯾﺠﺐ اﻟﺘﺨﻠﺺ‬
‫اﻟﻤﻨﺼﺎت ﻓﻰ أوﻋﯿﺔ ﺧﺎﺻﺔ‬ ‫ﻣﻨﮭﺎ طﺒﻤﺎ ﻟﻠﻤﻌﺎﯾﯿﺮ اﻟﺒﯿﺌﯿﺔ‬

‫=<< ھذا ﻣﺟرد ﺗﻘﯾﯾم أوﻟﻲ ﻣﺑﻧﻲ ﻋﻠﻰ اﻟﻣﻌﻠوﻣﺎت اﻟواردة ﻓﻲ اﻟﺷﮭﺎدة اﻟﻣرﻓﻘﺔ ﻣﻊ اﻟﻣﻧﺗﺞ وﻟﻠﻣذﯾد ﻣن اﻟﻣﻌﻠوﻣﺎت ﯾرﺟﻰ ﻣﺧﺎطﺑﺔ اﻟﻣورد‪.‬‬