PPE HAZARD ASSESSMENT CERTIFICATION FORM

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1 PPE HAZARD ASSESSMENT CERTIFICATION FORM Assessment Conducted By: Date: Name of Workplace: Workplace Address: City: State: Zip: Work Areas: Job / Task(s): (Use a separate form for each job / task or work area) The Following are some guidelines for complying with PPE requirements. This form should be used for a hazard assessment to see if your employees need to use personal protective equipment (PPE) by identifying activities that may create hazards for your employees. TABLE OF CONTENTS 2 Body / Whole 3 Body / Skin 4 Feet / Legs 5 Hands / Arms 6 Head 7 Face 8 Ears / Hearing 9 Eyes 10 Lungs / Repertory PPE Hazard Assessment Certification Page 1 of 10

2 BODY / WHOLE o Building maintenance o Construction o Computer work o Working outdoors o Logging o Utility work o Working from heights of 10 feet or more o Impact from flying objects o Impact from moving vehicles o Sharps injury o Blood o Electrical / static discharge o Hot metal o Musculoskeletal disorders o Sparks o Chemicals o Extreme heat / cold o Elevated walking / working surface o Working near water o Injury from slip / trip / fall o Fall arrest / restraint o Static coats / overalls o Insulated jacket o Hoist / lifts o Other: o Traffic vest o Flame resistant jacket / pants o Cut resistant sleeves / wristlets o Ergonomic equipment: With: o Hood o Full sleeves Notes: PPE Hazard Assessment Certification Page 2 of 10

3 BODY / SKIN o Baking or frying o Battery charging o Dip tank operations o Fiberglass installation o Sawing o Chemical splashes o Extreme heat o Extreme cold o Sharp or rough edges o Irritating chemicals o Vest / jacket o Raingear o Welding leathers o Other: o Coveralls / body suit o Apron o Abrasion / cut resistant With: o Long Sleeves Notes: PPE Hazard Assessment Certification Page 3 of 10

4 FEET / LEGS o Building maintenance o Construction o Demolition o Food processing o Foundry work o Working outdoors o Logging o Plumbing o Trenching o Use of highly flammable materials o Welding o Explosive atmospheres o Heavy equipment o Impact from objects o Crushing o Sharps injury o Extreme heat / cold o Fall o Explosives o Slippery surface o Pinch points o Slippery / wet surface o Blood o Chemical penetration o Exposed electrical wiring or components o Safety shoes or boots Toe protection Electrical protection Puncture resistance Metatarsal protection Heat / cold protection Chemical resistance Anti-slip soles o Leggings or chaps o Welding leathers o Foot / leg guards o Other: Notes: PPE Hazard Assessment Certification Page 4 of 10

5 HANDS / ARMS o Baking o Cooking o Grinding o Welding o Working with glass o Using computers o Using knives o Garbage disposal o Computer work o Material handling o Sanding o Sawing o Hammering o Using power tools o Working outdoors o Dental and health care services o Blood o Irritating chemicals o Extreme cold o Electric shock o Vibration o Hazardous tools / materials o Extreme heat o Animal bites o Musculoskeletal disorders o Sharp Injury o Gloves Chemical resistance Temperature resistance Slip resistance Liquid / leak resistance Abrasion / cut resistance Latex or nitrile Anti-vibration o Protective sleeves o Ergonomic equipment: o Other: Notes: PPE Hazard Assessment Certification Page 5 of 10

6 HEAD o Building maintenance o Construction o Electrical wiring o Catwalks o Conveyor Belts o Under crane loads o Utility work o Confined space o Beams o Pipes o Exposed electrical wiring or components o Falling objects o Fixed objects o Machine parts o Protective helmet Type A (low voltage) Type C o Hair net or soft cap Type B (high voltage) Bump Cap (not ANSI-approved) o Other: Notes: PPE Hazard Assessment Certification Page 6 of 10

7 FACE o Cleaning o Cooking o Siphoning o Painting o Dip tank operation o Pouring o Foundry work o Pouring Molten Metal o Working outdoors o Hazardous liquid chemicals o Extreme heat o Extreme cold o Potential irritants o Face shield o Welding shield o Shading / filter (# ) o Other: Notes: PPE Hazard Assessment Certification Page 7 of 10

8 EARS / HEARING o Generator o Motors o Sanding o Pneumatic equipment o Punch or break presses o Conveyors o Grinding o Machining o Routers o Sawing o Sparks o Loud noises o Loud environment o Punch or break presses o Ear muffs o Leather welding hood o Ear plugs Notes: PPE Hazard Assessment Certification Page 8 of 10

9 EYES o Abrasive blasting o Chopping o Cutting o Drilling o Welding o Soldering o Torch brazing o Working outdoors o Computer work o Punch press operations o Sanding o Sawing o Grinding o Hammering o Chipping o Airborne dust o Dirt o UV o Flying particles / objects o Blood splashes o Hazardous liquid chemicals mist o Chemical splashes o Molten metal splashes o Glare / high intensity lights o Laser operations o Intense lights o Hot sparks o Safety glasses o Dust-tight goggles o Welding helmet / shield o Chemical splash goggles o Shading / filter (# ) o Other: o Safety goggles o Impact goggles o Chemical goggles o Laser goggles o Welding shield With: o Side shield o Shaded o Face shield o Prescription Notes: PPE Hazard Assessment Certification Page 9 of 10

10 LUNGS / RESPITORY o Cleaning o Mixing o Painting o Fiberglass Installation o Confined work space o Floor installation o Ceiling repair o Working outdoors o Pouring o Sawing o Compresses air or gas operation o Dust or particulate o Chemical irritants (acids) o Asbestos o Organic vapors o Paint spray o Toxic gas / vapor o Welding fume o Pesticides o Oxygen deficient environment o Extreme heat / cold o Dust mask o Replaceable filter particulate w/ cartridge o PPSA (Air supply) o Disposable particulate respirator o PAPR (Air recycle) With: o Face shield o Organic cartridge o Spray paint cartridge o Full faced o Acid / gas cartridge o Pesticide cartridge o Half faced o Hood Notes: PPE Hazard Assessment Certification Page 10 of 10

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