PPE Checklist Template

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• **INSTRUCTIONS**
  Review the following audit to identify and evaluate need for Personal Protective Equipment in a given workplace.
  Answer "SAFE" if employee is not likely to be exposed to work condition listed below.
  Answer "AT RISK" if employee may be exposed to work condition

EYES

• Eye and Protection Criteria
  * Protect against specific hazard(s) encountered by employees
  * Comfortable to wear
  * Must not restrict vision or movement
  * Durable and easy to clean and disinfect
  * Must not interfere with the function of other required PPE
  * Meets requirements of ANSI Z87.1-1989 for devices purchased after July 5, 1992 and ANSI Z87.1-1968for devices purchased before that date

• Employees Perform tasks, or work near employees that perform tasks, that might produce airborne dust or flying particles

  Safe

  At Risk

  N/A

• Employees handle, or work near employees who handle hazardous liquid chemicals or encounter blood splashes

  Safe

  At Risk

  N/A

• Employees' eyes exposed to other potential physical or chemical irritants

  Safe

  At Risk

  N/A

• Employee exposed to intense light or lasers

  Safe

  At Risk

  N/A

FACE

• Eye and Protection Criteria
  * Protect against specific hazard(s) encountered by employees
  * Comfortable to wear
  * Must not restrict vision or movement
  * Durable and easy to clean and disinfect
  * Must not interfere with the function of other required PPE
  * Meets requirements of ANSI Z87.1-1989 for devices purchased after July 5, 1992 and ANSI Z87.1-1968for devices purchased before that date

• Employee handles or works near employees who handle hazardous liquid chemicals

  Safe

  At Risk

  N/A

• Employees' faces are exposed to extreme heat

  Safe

  At Risk

  N/A

• Employees' faces are exposed to other potential irritants

  Safe

  At Risk

  N/A

HEAD

• Tools or other objects may potentially fall from above and strike your employee on the head

  Safe

  At Risk

  N/A

• Employees' heads, when they stand or bend, are near exposed beams, machine parts, pipes, etc.?

  Safe

  At Risk

  N/A

• Employees work with or are in close proximity to electrical wiring or components of electrical wiring

  Safe

  At Risk

  N/A

FEET

• Tools, heavy equipment or other objects may potentially roll, fall onto or strike employees' feet

  Safe

  At Risk

  N/A

• Employees work with or are near exposed electrical wiring or electrical wiring components

  Safe

  At Risk

  N/A

• Employees handle or work with those who handle molten metal

  Safe

  At Risk

  N/A

• Employees work with explosives or are in an explosive atmosphere

  Safe

  At Risk

  N/A

HANDS

• Employees' hands may come into contact with tools or materials that might scrape, bruise or cut

  Safe

  At Risk

  N/A

• Employees handle chemicals that might irritate skin or come into contact with blood

  Safe

  At Risk

  N/A

• Employees place their hands and arms near extreme heat

  Safe

  At Risk

  N/A

• Employees' hands and arms are placed ear exposed electrical wiring or components

  Safe

  At Risk

  N/A

BODY

• Employees' bodies exposed to irritating dust or chemical splashes

  Safe

  At Risk

  N/A

• Employees' bodies exposed to sharp or rough surfaces

  Safe

  At Risk

  N/A

• Employees' bodies exposed to extreme heat

  Safe

  At Risk

  N/A

• Employees' bodies exposed to acids or other hazardous substances

  Safe

  At Risk

  N/A

HEARING

• Employees are exposed to loud noise from machines, tools, music systems, etc.

  Safe

  At Risk

  N/A