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

  • Additional person assisting with assessment

  • Signature

Eyes

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work-related exposure to (check all that apply):

  • List "other" work related exposures.

  • Can hazard be eliminated without the use of PPE?

  • If no, use (check all that apply):

  • List "other" PPE to be worn.

Face

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work related activities.

  • Work related exposure to (check all that apply):

  • 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.

Head

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work related exposure to (check all that apply):

  • 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.

Hands / Arms

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work related exposure to (check all that apply):

  • List "other" work related exposure.

  • Can hazard be eliminated without the use of PPE?

  • If no, use (check all that apply):

  • Type of glove (check all that apply):

  • List ergonomic equipment.

  • List "other" PPE to be worn.

Feet / Legs

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work related exposure to (check all that apply):

  • List "other" work-related exposure.

  • Can hazard be eliminated without the use of PPE?

  • If no, use (check all that apply):

  • Type of safety shoe or boot (check all that apply):

  • List "other" PPE to be worn.

Body / Skin

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work related exposure to (check all that apply):

  • 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.

Body / Whole

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work related exposure to (check all that apply):

  • List "other" work related exposure.

  • Can hazard be eliminated without the use of PPE?

  • If no, use (check all that apply):

  • List "ergonomic equipment" to be used.

  • List "other" PPE to be worn.

Lungs / Respiratory

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activities.

  • Work related exposure to (check all that apply):

  • 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.

Ears / Hearing

  • Check box if a hazard exists. An unchecked box indicates there is no hazard for this portion of the body.

  • Work activities, such as (check all that apply):

  • List "other" work activites.

  • Work related exposure to (check all that apply):

  • 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.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.