Personal Protective Equipment Hazard Assessment

Title Page

Site conducted
Equipment / job tasks
Date conducted
I certify that I personally performed the below Personal Protective Hazard Assessment on the date indicated.
Person performing assessment
Person performing assessment signature

Eyes

Face

Work activities, such as (check all that apply):
- cleaning
- cooking
- siphoning
- painting
- dip tank operations
- pouring
- welding
- mixing
- working outdoors
- other
List "other" work related activities.
Work related exposure to (check all that apply):
- hazardous liquid chemicals
- extreme heat
- extreme cold
- potential irritants
- other
List "other" work-related exposure.
Can hazard be eliminated without the use of PPE?
If no, use (check all that apply):
- face shield
- shading / filter
- welding shield
- other
List "other" PPE to be worn.

Head

Work activities, such as (check all that apply):
- building maintenance
- confined space operations
- construction
- electrical wiring
- walking / working under catwalks
- walking / working on catwalks
- walking / working under conveyor belts
- walking / working around conveyor belts
- walking / working around crane loads
- utility work
- other
List "other" work activities.
Work related exposure to (check all that apply):
- beams
- pipes
- exposed electrical wiring or components
- falling objects
- fixed objects
- machine parts
- other
List "other" work-related exposure
Can hazard be eliminated without the use of PPE?
If no, use (check all that apply):
- protective helmet (hard hat)
- hair net or soft cap
- other
- bump cap (not ANSI-approved)
List "other" PPE to be worn.

Hands / Arms

Work activities, such as (check all that apply):
- baking
- cooking
- grinding
- welding
- working with glass
- using computers
- using knives
- garbage disposal
- material handling
- sanding
- sawing
- hammering
- using power tools
- working outdoors
- other
List "other" work activities.
Work related exposure to (check all that apply):
- blood
- irritating chemiclas
- tools or materials that could scrape, bruise or cut
- extreme heat
- extreme cold
- animal bites
- electric shock
- vibration
- musculoskeletal disorders
- sharps injury
- other
List "other" work related exposure.
Can hazard be eliminated without the use of PPE?
If no, use (check all that apply):
- gloves
- protective sleeves
- ergonomic equipment
- other
Type of glove (check all that apply):
- chemical resistant
- liquid / leak resistant
- temperature resistant
- abrasion / cut resistant
- slip resistant
- latex or nitrile
- anti-vibration
List ergonomic equipment.
List "other" PPE to be worn.

Feet / Legs

Work activities, such as (check all that apply):
- building maintenance
- construction
- demolition
- food processing
- working outdoors
- trenching
- use of highly flammable materials
- welding
- other
List "other" work activities.
Work related exposure to (check all that apply):
- explosive atmospheres
- explosives
- exposed electrical wiring or components
- heavy equipment
- slippery surfaces
- impact from objects
- pinch points
- crushing
- slippery / wet surface
- sharps injury
- other
- blood
- chemical splash
- chemical penetration
- extreme heat / cold
- fall
List "other" work-related exposure.
Can hazard be eliminated without the use of PPE?
If no, use (check all that apply):
- safety shoes or boots
- leggings or chaps
- foot / leg guards
- other
Type of safety shoe or boot (check all that apply):
- toe protection
- electrical protection
- puncture resistance
- anti-slip soles
- metatarsal protection
- heat / cold protection
- chemical resistance
List "other" PPE to be worn.

Body / Skin

Body / Whole

Lungs / Respiratory

Ears / Hearing

Work activities, such as (check all that apply):
- generator
- ventilation fans
- motors
- sanding
- pneumatic equipment
- manufacturing equipment
- use of conveyors
- grinding
- sawing
- machining
- routers
- sparks
- other
List "other" work activites.
Work related exposure to (check all that apply):
- loud noises (intermittent)
- loud work environment (continuous)
- noisy machines / tools
- other
List "other" work-related exposure.
Can hazard be eliminated without the use of PPE?
If no, use (check all that apply):
List "other" PPE to be worn.

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