Title Page

  • Company Name

  • Client / Site

  • Conducted on

  • Prepared by

  • Location

PPE Evaluation Form

  • Nature of work

  • Identify potential hazards at work (select all that apply)

EYE HAZARDS

  • Handling/dispensing chemicals and ingredients; working around UV lights; chipping, sanding, grinding, welding, metal working; tasks that generate dust

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

HEAD/NECK/FACE HAZARDS

  • Handling/dispensing chemicals and ingredients, chipping, sanding or grinding metal or wood; working below others, working on energized equipment, working in confined spaces

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

FOOT HAZARDS

  • Exposure to chemicals; wet environments; welding and cutting; material handling; uneven walking/working surfaces

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

HAND HAZARDS

  • Handling/dispensing chemicals and ingredients; exposure to abrasive materials; using knives or other sharp objects; working with hot or cold materials; food service prep

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

BODY/TORSO HAZARDS

  • Handling/dispensing chemicals or ingredients; exposure to abrasive materials; cutting, brazing, welding, chipping or sanding; working around electrical panels

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

FALL HAZARDS

  • Working on raised surfaces of 4 feet or morel; ladder use

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

NOISE HAZARDS

  • Noise levels above 85 dBA; working around pneumatic equipment; using powered hand tools

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

RESPIRATORY HAZARDS

  • Handling/using highly hazardous chemicals; tasks that generate dust and/or fumes; cutting, brazing on certain metals (stainless steel);

  • Select all that apply for each hazard from the drop down list.

  • Description of Hazard

  • Required PPE

  • Does the equipment undergo testing and in a good condition?

  • Take a photo

  • Does the equipment fit perfectly?

  • Take a photo

RECOMMENDATION

  • State recommendations here

COMPLETION

  • Auditor's Full Name and Signature

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.