Sample PPE Hazard Assessment Certification Form

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1 Sample PPE Hazard Assessment Certification Form Found in the OSHA General Industry Standard 29 CFR is the requirement for employers to conduct a workplace assessment of the hazards that may be present where Personal Protective Equipment (PPE) will be used to protect workers. The OSHA standard requires the employer show the workplace assessment was performed through a written certification that identifies the workplace evaluated; the person certifying the assessment was performed and the dates the assessment took place. Performing the Assessment For each job task, or area of a facility, complete a separate certification form. The assessment should be completed by an employee who is familiar with the type of work performed, the hazards associated with the task or in the area and the proper PPE that should be used to protect employees. Training Workers need to be trained on the proper use, fitting, cleaning and storage of any PPE they may be required to use for protection. When training employees a written training certification should also be completed and maintained on file. continued

2 PPE Hazard Assessment Certification Form *Name of work place: *Assessment conducted by: *Work place address: *Date of assessment: Work area(s): Job/Task(s): Eyes o abrasive blasting o chopping o cutting o drilling o welding o punch press operations o airborne dust o flying particles o blood splashes o hazardous liquid chemicals o intense light o Safety glasses Face o cleaning o cooking o siphoning o painting o dip tank operations o hazardous liquid chemicals o extreme heat/cold o potential irritants: o Face shield o Shading/Filter (# ) o Welding shield o Safety goggles o Shading/Filter (# ) o Welding shield *Required for certifying the hazard assessment. Use a separate sheet for each job/task or work area. 2

3 Head o building maintenance o confined space operations o construction o electrical wiring o walking/working under catwalks o walking/working under conveyor belts o walking/working under crane loads o utility work o beams o pipes o exposed electrical wiring or components o falling objects o machine parts o Protective Helmet o Type A (low voltage) o Type B (high voltage) o Type C o Bump cap (not ANSI-approved) o Hair net or soft cap Hands/Arms o baking o cooking o grinding o welding o working with glass o using computers o using knives o dental and health care services o blood o irritating chemicals o tools or materials that could scrape, bruise, or cut o extreme heat/cold o Gloves o Chemical resistance o Liquid/leak resistance o Temperature resistance o Abrasion/cut resistance o Slip resistance o Protective sleeves 3

4 Feet/Legs o building maintenance o construction o demolition o food processing o foundry work o logging o plumbing o trenching o use of highly flammable materials o welding o explosive atmospheres o explosives o exposed electrical wiring or components o heavy equipment o slippery surfaces o tools o Safety shoes or boots Body/Skin o baking or frying o battery charging o dip tank operations o fiberglass installation o irritating chemicals o sawing o chemical splashes o extreme heat/cold o sharp or rough edges o Vest, Jacket o Coveralls, Body suit o Raingear o Apron o Welding leathers o Abrasion/cut resistance o Toe protection o Electrical protection o Puncture resistance o Anti-slip soles o Heat/cold protection o Chemical resistance o Leggings or chaps o Foot-Leg guards 4

5 Body/Whole o building maintenance o construction o logging o utility work o working from heights of 4 feet or more o working near water o Fall Arrest/Restraint: o Type: o PFD: o Type: Lungs/Respiratory o cleaning o pouring o mixing o sawing o painting o fiberglass installation o compressed air or gas operations o irritating dust or particulate o irritating or toxic gas/vapor o Air Purifying Respirator o Type: o Supplied Air Respirator Refer to workplace respiratory protection program *(See Footnote 1) 5

6 Segment Hanover BAND Risk Solutions Ears/Hearing o generator o grinding o ventilation fans o machining o motors o routers o sanding o sawing o pneumatic equipment o punch or brake presses o use of conveyors o loud noises o Disposable Inserts with NRR of o Ear Muffs with NRR of Refer to workplace hearing protection program *(See Footnote 1) (1) NOTE: There are other hazards requiring PPE (such as respiratory, noise, fall hazards), that require additional training and written programs. Reference Washington Department of Labor and Industry s c To learn more about Hanover Risk Solutions, visit hanoverrisksolutions.com o loud work environment o noisy machines/tools o punch or brake presses The Hanover Insurance Company 440 Lincoln Street, Worcester, MA hanover.com The Agency Place (TAP) The recommendation(s), advice and contents of this material are provided for informational purposes only and do not purport to address every possible legal obligation, hazard, code violation, loss potential or exception to good practice. The Hanover Insurance Company and its affiliates and subsidiaries ( The Hanover ) specifically disclaim any warranty or representation that acceptance of any recommendations or advice contained herein will make any premises, property or operation safe or in compliance with any law or regulation. Under no circumstances should this material or your acceptance of any recommendations or advice contained herein be construed as establishing the existence or availability of any insurance coverage with The Hanover. By providing this information to you, The Hanover does not assume (and specifically disclaims) any duty, undertaking or responsibility to you. The decision to accept or implement any recommendation(s) or advice contained in this material must be made by you (02/14) LC

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