PERSONAL PROTECTIVE EQUIPMENT WORKSITE HAZARD ASSESSMENT
(per 1910.132)
SITE / TASK:
HEAD 29 CFR 1910.135 1. Struck By 2. Struck Against 3. Electrical 4. Thermal 5.Other: RESPIRATORY 29 CFR 1910.134 1. Oxygen Deficiency 2. Airborne Particulates a. Dusts b. Fumes c. Mists 3. Airborne Contaminants a. Gases b. Vapors 4. Combination 5. Thermal 6. Other: FOOT / LEG 29 CFR 1910.136 1. Cut / Abrasion / Puncture / Crush 2. Electrical 3. Chemical 4. Biological 5. Thermal 6. Body Fluids 7. Strain 8. Struck By / Struck Against 9.Cumulative 10. Other: AUDITORY 29 CFR 1910.95 1. Ambient Level Above 85 dBa 2. Impact Level Above 85 dBa 3. Other: COMMENTS: CERTIFICATION: I certify this WORKSITE HAZARD ASSESSMENT was conducted and / or the current files reviewed. Appropriate Personal Protective Equipment or additional Safeguards utilized per the hazards noted and/or anticipated. Signature: Date: EYES / FACE 29 CFR 1910.133 1. Airborne 2. Chemical 3. Flash /Light / UV 4. Struck By / Struck Against 5. Other: HAND / ARM 29 CFR 1910.138 1. Cut / Abrasion / Puncture / Crush 2. Electrical 3. Chemical 4. Biological 5. Thermal 6. Body Fluids 7. Strain 8. Struck By / Struck Against 9. Cumulative 10. Other:
TORSO / WHOLE BODY MISC. STANDARDS 1. Cut / Abrasion / Puncture / Crush 2. Electrical 3. Chemical 4. Biological 5. Thermal 6. Body Fluids 7. Strain 8. Struck By / Struck Against 9. Cumulative 10. Slip / Trip / Fall a. Same Level b. Different Level 11. Entrapment 12. Submersion / Immersion / Fluids 13. Other:
PAGE TWO WORKSITE HAZARD ASSESSMENT
PERSONAL PROTECTIVE EQUIPMENT GUIDANCE
HEAD 1. Hard Hat-Type I or II, G, E, or C 2. Hard Hat-Type I or II, G, E, or C 3. Hard Hat-Type I or II, E 4. Hard Hat w/ Liner or Sweatband 5. Hard Hat per Hazard noted and/or Anticipated RESPIRATORY 1. SCBA or Supplied-air Respirator 2. Filter Selection per MSDS or Hazard Anticipated w/ Administrator Confirmation 3. Filter Selection per MSDS or Hazard Anticipated / Administrator Confirmation 4. Filter per MSDS w/ Program Administrator Confirmation 5. SCBA or Supplied Air, Tempered 6. Protection per MSDS or Hazard Anticipated w/ Approval of Program Administrator EYES / FACE 1. Impact-resistant Eyewear with Side Shields, Full Face Shield 2. Non-vented Goggles, Full Faceshield 3. Filters or Tinted Lens 4. Impact-resistant Eyewear 5. Eyewear Appropriate to Hazard HAND / ARM 1. Gloves/Sleeves-Kevlar, Mesh, Leather, or Canvas per Hazard 2. Gloves/Sleeves-Dielectric 3. Gloves/Sleeves-Resistant to Materials Involved or Anticipated 4. Gloves/Sleeves-Appropriate for Hazard Anticipated 5. Gloves/Sleeves-Insulated, etc. 6. Gloves/Sleeves-Latex, Nitrile, etc. 7. Proper Techniques, Tools, Assists 8. Heavy-Duty Gloves/Sleeves 9. Assists, Techniques 10. Gloves/Sleeves per Hazard TORSO / WHOLE BODY 1. Adequate Clothing, Technique 2. Proper Technique & Training 3. Impervious Coveralls, Suits 4. Impervious Coveralls, Suits 5. Insulated Coveralls, Cool Suit 6. Impervious Coveralls, Suits 7. Improved Techniques, Training 8. Improved Techniques, Training 9. Improved Techniques, Training 10. Restraints, Techniques, Training 11.With Supervisory Approval Only 12. PFD’s, Tether, Rescue Harness 13. With Supervisory Approval Only ADDITIONAL COMMENTS:
FOOT / LEG 1. Appropriate Safety Footwear & Clothing/Leg Guards 2. Non-Metallic Safety Footwear 3. Resistant Coveralls/Footwear 4. Impervious Coverall, Footwear 5. Insulated Footwear/Clothing 6. Impervious Coverall/Footwear 7. Proper Techniques, Tools, Assists 8. Safety Footwear, Leg Guards 9. Assists, Techniques 10. Footwear/Clothing per Hazard
AUDITORY 1. Appropriate NRR Ear Plugs or Muffs 2. Appropriate NRR Ear Plugs or Muffs