Title Page
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Site conducted
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Equipment / job tasks
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Date conducted
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I certify that I personally performed the below Personal Protective Hazard Assessment on the date indicated.
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Person performing assessment
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Person performing assessment signature
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Additional person assisting with assessment
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Signature
Eyes
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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Work activities, such as (check all that apply):
- abrasive blasting
- chopping
- cutting
- drilling
- welding
- soldering
- torch brazing
- working outdoors
- computer work
- sanding
- sawing
- grinding
- hammering
- chipping
- other
- Cleaning with compressed air
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List "other" work activities.
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Work-related exposure to (check all that apply):
- airborne dust
- dirt
- UV
- flying particles / objects
- blood splashes
- hazardous liquid chemicals mists
- chemical splashes
- glare / high intensity lights
- laser operations
- intense light
- hot sparks
- other
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List "other" work related exposures.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- safety glasses
- safety goggles
- dust-tight goggles
- impact goggles
- welding helmet / shield
- chemical goggles
- chemical splash goggles
- laser goggles
- shading / filter
- welding shield
- other
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List "other" PPE to be worn.
Face
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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Work activities, such as (check all that apply):
- cleaning
- cooking
- siphoning
- painting
- dip tank operations
- pouring
- welding
- mixing
- working outdoors
- other
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List "other" work related activities.
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Work related exposure to (check all that apply):
- hazardous liquid chemicals
- extreme heat
- extreme cold
- potential irritants
- other
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List "other" work-related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- face shield
- shading / filter
- welding shield
- other
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List "other" PPE to be worn.
Head
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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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
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List "other" work activities.
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Work related exposure to (check all that apply):
- beams
- pipes
- exposed electrical wiring or components
- falling objects
- fixed objects
- machine parts
- other
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List "other" work-related exposure
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- protective helmet (hard hat)
- hair net or soft cap
- other
- bump cap (not ANSI-approved)
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List "other" PPE to be worn.
Hands / Arms
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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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
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List "other" work activities.
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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
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List "other" work related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- gloves
- protective sleeves
- ergonomic equipment
- other
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Type of glove (check all that apply):
- chemical resistant
- liquid / leak resistant
- temperature resistant
- abrasion / cut resistant
- slip resistant
- latex or nitrile
- anti-vibration
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List ergonomic equipment.
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List "other" PPE to be worn.
Feet / Legs
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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Work activities, such as (check all that apply):
- building maintenance
- construction
- demolition
- food processing
- working outdoors
- trenching
- use of highly flammable materials
- welding
- other
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List "other" work activities.
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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
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List "other" work-related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- safety shoes or boots
- leggings or chaps
- foot / leg guards
- other
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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
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List "other" PPE to be worn.
Body / Skin
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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Work activities, such as (check all that apply):
- baking or frying
- battery charging or changing
- dip tank operations
- fiberglass installation
- sawing
- other
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List "other" work activities.
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Work related exposure to (check all that apply):
- chemical splashes
- extreme heat
- extreme cold
- sharp or rough edges
- irritating chemicals
- other
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List "other" work related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- vest / jacket
- coveralls / body suit
- raingear
- apron
- welding leathers
- abrasion / cut resistance
- other
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List "other" PPE to be worn.
Body / Whole
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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Work activities, such as (check all that apply):
- building maintenance
- construction
- computer work
- working outdoors
- utility work
- other
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List "other" work activities.
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Work related exposure to (check all that apply):
- working from heights of 4 feet or more
- impact from flying objects
- impact from moving vehicles
- sharps injury
- blood
- electrical / static discharge
- hot metal
- musculoskeletal disorders
- sparks
- chemicals
- extreme heat
- extreme cold
- elevated walking / working surface
- working near water
- injury from slip / trip / fall
- other
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List "other" work related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- fall arrest / restraint
- traffic vest
- static coats / overalls
- flame resistant jacket / pants
- insulated jacket
- cut resistant sleeves / wristlets
- hoists / lifts
- ergonomic equipment
- other
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List "ergonomic equipment" to be used.
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List "other" PPE to be worn.
Lungs / Respiratory
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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Work activities, such as (check all that apply):
- cleaning
- mixing ingredients
- painting
- fiberglass installation
- compressed air or gas operations
- confined space work
- floor installation
- ceiling repair
- working outdoors
- pouring
- sawing
- other
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List "other" work activities.
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Work related exposure to (check all that apply):
- dust or particulate
- toxic gas / vapor
- chemical irritants
- welding fume
- asbestos
- pesticides
- organic vapors
- oxygen deficient environment
- paint spray
- extreme cold
- extreme heat
- COVID-19 (based on CDC guidelines)
- other
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List "other" work related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
- NIOSH certified N-95 type filtering facepiece
- disposable particulate respirator
- replaceable filter particulate with cartridge
- PAPR (air recycle)
- PPSA (air supply)
- disposable non-surgical face mask
- other
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List "other" PPE to be worn.
Ears / Hearing
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Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.
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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
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List "other" work activites.
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Work related exposure to (check all that apply):
- loud noises (intermittent)
- loud work environment (continuous)
- noisy machines / tools
- other
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List "other" work-related exposure.
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Can hazard be eliminated without the use of PPE?
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If no, use (check all that apply):
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List "other" PPE to be worn.
