CIH Professional Reference Questionnaire (PRQ) CIH PRQ Form "*" indicates required fields Step 1 of 6 - Application Data 16% Applicant Data THIS QUESTIONNAIRE IS TO BE COMPLETED BY THE REFERENCE WRITER ONLY Directions: This is the online form to submit a professional reference for an individual applying for the Certified Industrial Hygienist (CIH) credential. An applicant's spouse, other relatives, or a person whom the applicant supervises may not serve as a reference. References will not be accepted if written by the applicant. Please familiarize yourself with the requirements and the details of this form before you start. Doing so will enable you to answer all questions as completely as possible. This form must be completed in one sitting. To prevent loss of data should a connection error occur, we suggest writing you answers in a separate program (such as Word) and then cut/paste your answers into this form. For a list of questions that need answering, please click here. When you have finished the form, please click Submit. Attestation: I personally composed this Professional Reference Questionnaire. All the information contained in it is true, complete, and accurate to the best of my knowledge. I am not related to the applicant and have not worked under the applicant's supervision. We may call or email you to verify you are the writer of this form.I agree to use electronic records and signatures.* I agree to use electronic records and signatures. Typed Signature* Date* MM slash DD slash YYYY Name of Applicant* Person Writing Reference* Do you know of any reason why this Applicant should not be considered for certification?* Yes No Please explain "Yes" aboveAre you capable of providing an informed and objective description of the Applicant's professional-level work in industrial hygiene?* Yes No Please explain "No" abovePlease indicate the time period during which you have personal knowledge of the Applicant's industrial hygiene work experience and the nature of your association with the Applicant. If you wish to enter more than one time period, please select the "Other" box and add information as needed. Supervisor Supervisor Sup from MM slash DD slash YYYY Sup To MM slash DD slash YYYY Colleague (non-Supervisory) Colleague (non-Supervisory) Colleague From MM slash DD slash YYYY Colleague To MM slash DD slash YYYY Professor Professor Professor From MM slash DD slash YYYY Professor To MM slash DD slash YYYY Client Client Client From MM slash DD slash YYYY Client To MM slash DD slash YYYY Other Other Other From MM slash DD slash YYYY Other To MM slash DD slash YYYY Text Explain "other" or more info Work History 1 Industrial Hygiene is the science and practice devoted to the anticipation, recognition, evaluation, and control of those environmental factors and stresses arising in or from the workplace that may cause sickness, impaired health and well-being, or significant discomfort among workers and may also impact the general community. Qualifying Experience means the individual has demonstrated professional-level work experience including the ability: to anticipate and recognize workplace environmental factors and stresses (i.e. chemical, physical, biological, ergonomic) and to understand their effects on people and their well-being to evaluate (through observation, sampling, and testing) the magnitude of these factors and stresses to prescribe methods (i.e., engineering, administrative, personal protective equipment, training) to prevent, eliminate, control, or reduce such factors and stresses and their effects to manage industrial hygiene programs In the following spaces, please describe the Applicant's industrial hygiene functions and activities for each position held during the time periods for which you have direct personal knowledge. Position 1 Title* Date From* MM slash DD slash YYYY Date To* MM slash DD slash YYYY Date professional-level industrial hygiene practice began for this job, if different from the employment start date: Date pro level began* MM slash DD slash YYYY Average number of hours per week devoted to professional-level industrial hygiene practice:Hours/week* What percentage of total work time is devoted to the practice of professional-level industrial hygiene practice? Percent total work time in IH* Describe specific work functions and activities, addressing the criteria listed below. Make your answers as detailed as possible; general or vague responses will delay the application process.Depth of Work*Level of interaction*Responsibilty for Work Outcome* Position 2 Title Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Date professional-level industrial hygiene practice began for this job, if different from the employment start date: Date pro level began MM slash DD slash YYYY Average number of hours per week devoted to professional-level industrial hygiene practice:Hours/week What percentage of total work time is devoted to the practice of professional-level industrial hygiene practice? Percent total work time in IH Describe specific work functions and activities, addressing the criteria listed below:Depth of WorkLevel of interactionResponsibilty for Work Outcome Position 2 Title Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Date professional-level industrial hygiene practice began for this job, if different from the employment start date: Date pro level began MM slash DD slash YYYY Average number of hours per week devoted to professional-level industrial hygiene practice:Hours/week What percentage of total work time is devoted to the practice of professional-level industrial hygiene practice? Percent total work time in IH Describe specific work functions and activities, addressing the criteria listed below:Depth of WorkLevel of interactionResponsibilty for Work Outcome Autonomy / EthicsDescribe the Applicant's ability to perform with independent technical responsibility and identify any significant technical deficiencies.Does the Applicant conduct industrial hygiene activities in a manner consistent with the BGC Code of Ethics?Does the Applicant conduct product stewardship activities in a manner consistent with the BGC?* Yes No Ethics Reference DataName* First Last Company/ Organization Division Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* If you are certified by the Board for Global EHS Credentialing (BGC) or at the professional level by an organization whose industrial/occupational scheme is recognized by the International Occupational Hygiene Association (IOHA), please indicate your credential and certificate number or share your digital badge URL.If you are certified by the Board for Global EHS Credentialing (BGC), please indicate your certificate number ALL references and supporting materials must be submitted no later than February 1 immediately preceding the spring examinations and no later than August 1 immediately preceding the fall examinations. CIH Candidate Handbook About the CIH Overview of Steps Reapplicants Eligibility Requirements Academic Coursework Experience ABET IH Programs Ethics Eligibility Checklist Documents Needed Education Transcripts International Degrees CIH PRQ Form Dates, Deadlines, and Fees Examination Overview Format Exam Scoring Exam Results Exam Pass Rate Exam Preparation Publications and References Sample Questions Exam Blueprint Equation Sheets Examination Scheduling Examination Day Documents and Forms Apply Now
