Title Page
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Company Name
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Client / Site
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Conducted on
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Prepared by
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Location
PPE Evaluation Form
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Nature of work
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Identify potential hazards at work (select all that apply)
- Eye
- Head/Neck/Face
- Foot
- Hand
- Body/Torso
- Fall
- Noise
- Respiratory
EYE HAZARDS
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Handling/dispensing chemicals and ingredients; working around UV lights; chipping, sanding, grinding, welding, metal working; tasks that generate dust
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
HEAD/NECK/FACE HAZARDS
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Handling/dispensing chemicals and ingredients, chipping, sanding or grinding metal or wood; working below others, working on energized equipment, working in confined spaces
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
FOOT HAZARDS
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Exposure to chemicals; wet environments; welding and cutting; material handling; uneven walking/working surfaces
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
HAND HAZARDS
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Handling/dispensing chemicals and ingredients; exposure to abrasive materials; using knives or other sharp objects; working with hot or cold materials; food service prep
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
BODY/TORSO HAZARDS
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Handling/dispensing chemicals or ingredients; exposure to abrasive materials; cutting, brazing, welding, chipping or sanding; working around electrical panels
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
FALL HAZARDS
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Working on raised surfaces of 4 feet or morel; ladder use
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
NOISE HAZARDS
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Noise levels above 85 dBA; working around pneumatic equipment; using powered hand tools
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
RESPIRATORY HAZARDS
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Handling/using highly hazardous chemicals; tasks that generate dust and/or fumes; cutting, brazing on certain metals (stainless steel);
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Select all that apply for each hazard from the drop down list.
- Chemical Exposure
- Cut/Abrasions
- Dust/Flying Debris
- Dust Particulates
- Electrical Arc
- Electrical Shock
- Fall Hazard
- High Heat/COld
- Impact
- Impact/Compression
- UV/IR Radiation
- Noise Hazard
- Puncture
- Slippery/Wet Surfaces
- Other
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Description of Hazard
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Required PPE
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Does the equipment undergo testing and in a good condition?
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Take a photo
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Does the equipment fit perfectly?
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Take a photo
RECOMMENDATION
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State recommendations here
COMPLETION
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Auditor's Full Name and Signature
