PPE Hazard Assessment Certification Form - DOC by jtl17221

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									                                 PPE Hazard Assessment Certification Form
Name of work place:                                                    Assessment conducted by:
Work place address:                                                    Date of assessment:
Work area(s):                                                          PPE Selected By:
Job/Task(s):                                                           Effective Date:
EYES/FACE                                Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     airborne dust                                 Safety glasses
     flying particles                              Safety goggles
     hazardous liquids/chemicals                   Face Shield
     intense light                                 Shading/Filter (#            )
     blood splashes                                Welding shield
     other:                                        Other:

HEAD                                     Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     beams                                         Protective Helmet
     pipes                                              Type A (low voltage)
     falling objects                                    Type B (high voltage)
     exposed electrical wiring or components            Type C
     machine parts                                 Hair net or soft cap
     other:                                        Other:

HANDS/ARMS                               Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     hazardous liquids/chemicals                   Gloves
     scrapes, bruise, or cut                         Chemical resistance                   Liquid/leak resistance
     injuries from tools                             Temperature resistance                Cut resistance
     extreme heat/cold                               Gauntlet or long necked               Work Gloves
     blood (OPIM)                                  Chemical Protective sleeves
     other:                                        Long sleeves
                                                   Other:

FEET/LEGS                                Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     hazardous liquids/chemicals                   closed shoes (e.g. no opened toes or sandals)
     heavy falling/rolling objects                 long pants
     heavy equipment                               Safety shoes or boots
     exposed electrical wiring or components            Toe protection                     Metatarsal protection
     slippery surfaces                                  Electrical protection              Heat/cold protection
     explosive atmospheres                              Anti-slip soles                    Chemical resistance
     tools                                         Leggings or chaps
     other:                                        Foot-Leg guards
                                                   Other:

BODY/SKIN                                Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     hazardous liquids/chemicals                   Lab Coat                               Raingear
     sharp or rough edges                          Coveralls, Body suit                   Apron
     extreme heat/cold                             Welding leathers                       Abrasion/cut
     other:                                        Other:                                 resistance

BODY/WHOLE                               Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     working from heights of 4 feet or more      Fall Arrest/Restraint: Type:
     working near water                          PFD: Type:
     other:                                      Other:

LUNGS/EARS                               Negligible Hazard                          Can hazard be eliminated without the use of PPE? Yes   No
Work-related exposure to:                      PPE required to manage hazard:                                       Comments:
     irritating dust or particulate                 Respirator (Cartridge type:              )
     irritating or toxic gas/vapor                  Particulate Mask
     loud work environment                          Hearing Protection
     noisy machines/tools
     other:



                                                   PPE Hazard Assessment Certification

								
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