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DATE :
NOM : Prénom :
ENTREPRISE :
DATE D'EMBAUCHE : DATE DE SORTIE : DUREE D'EXPOSITION :
ACTIVITES

Evaluation : 0 = néant 1 = occasionnel 2 = fréquent 3 = permanent
  Evaluation   Evaluation
Passe l'aspirateur   Décape les revêtements de sol  
Balaie à l'humide   Ponce les parquets  
Lave au Faubert   Cire, vitrifie les parquets  
Lave à la serpillière   Applique une peinture sur ciment  
Vide les corbeilles et poubelles   Nettoie les moquettes  
Dépoussière les meubles   Lustre les marbres  
Nettoie les sanitaires   Enlève les graffitis  
Nettoie les vitres   Entretien le matériel, remplissage du réservoir  
Nettoie les hottes aspirantes      
CONDITIONS DE TRAVAIL

Entourer l'item adéquat
Horaires Journée  Nuit  Alternés  2 périodes (matin/soir)
Décalés par rapport aux horaires de bureau : matin tôt, soirée  Autres
Déplacements hors entreprise Locaux  Régionaux
Contraintes organisationnelles et relationnelles Dépassement d'horaire  Rythme imposé  Travail isolé
Travail en équipe  Relations hiérarchie  Contact public
Bruit Oui  Non
Ambiance thermique Intempéries  Chaleur  Chambre frigorifique  Courants d'air
Travail en air et espace contrôlé Climatisation
Conduite et machines VL  Monobrosse  Balayeuse  Autolaveuse  Machine haute pression  Machine à shampooing
Autres Humidité (travail au jet)
RISQUES LIES AUX ACTIVITES

Evaluation : 0 = néant 1 = occasionnel 2 = fréquent 3 = permanent 4 = surveillance médicale renforcée
Liés à une maladie professionnelle et/ou SMR Evaluation MPI Risques autres Evaluation
Ethers de glycol (dont certains sont cancérogènes)     Irritation des voies aériennes supérieures par produits  
Risque biologique (milieu de soin)     Dorsalgies, lombalgies
Collecte des ordures     Contraintes posturales  
Aff. dig. benzène toluène xylène   4 bis Irritation cutanée  
Dérivés halogénés HC aromatiques   9 Intoxication par le chlore (mélange d'eau de javel et d'acide)  
Dérivés halog. HC aliphatiques   12 Brûlures chimiques: acide, soude  
Fluor, acide fluorhydrique, sels   32 Risque routier  
Bacille tuberculeux (milieu soins   40 Coupures, contusions  
Hépatite (milieu de soins)   45 Risque infectieux :déchets, sanitaires  
Aff.cutanées et respiratoires amines aliphatiques   49
49 bis
Chutes de hauteur, sur sol glissant, dans les escaliers  
Polio (milieu de soins)   54 Sida  
Amibes (milieu de soins)   45    
Affections périarticulaires   57    
Lésions eczématiformes   65    
Rhinites et asthme   66    
Pneumopathies d'hypersensibilité   66 bis    
Maladies infectieuses hospitalières   76    
Solvants   84    
Latex   95    
Hantavirus   96    
Affections rachis charges lourdes   98    
Aldéhyde formique   43    
PROTECTIONS INDIVIDUELLES ET COLLECTIVES

Fréquence d'utilisation : 1 = occasionnellement 2 = fréquemment 3 = en permanence
  Type Disponible Utilisé Fréquence d'utilisation
Masque        
Lunettes / visière        
Vêtements de travail        
Gants        
Crème barrière        
Harnais de sécurité        
Chaussures de sécurité        
Autres        
SURVEILLANCE MEDICALE LIEE AUX RISQUES
Examens complémentaires Réglementaire = R
Conseillé = C
Oui Fréquence
Radiographie pulmonaire C milieu de soins    
Examen de la vision C    
NFS C    
Enzymes hépatiques C  
Tests d'allergie cutanée C    
Vaccinations
BCG R milieu de soins    
DTPolio R milieu de soins    
Hépatite B R milieu de soins    
Hépatite A C    
Leptospirose C    
ACTIVITES DE TIERS TEMPS
Sonométrie : Ambiance lumineuse :
Prélèvements atmosphériques :  
AUTEURS : Catherine Vollet (médecin du travail), Béatrice Muller (médecin du travail), Dominica Feron (médecin du travail) (Médecine du travail Durance Luberon) (84)
D'APRES LA fiche d'activité professionnelle Bossons Futé n°27Agent de propreté
DATE DE CREATION : Octobre 2003
DERNIERE MISE A JOUR : Octobre 2003

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