PPE Evaluation Form

• Company Name

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• INSTRUCTIONS
  
  1. Answer the following questions by typing in your answers in the text field.
  2. On the dropdown list, select the items that apply to each hazard.
  3. Indicate the description of the hazard and the required PPE.
  4. Complete audit by providing digital signature

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

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.

  Select 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

  • 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

• Description of Hazard

• Required PPE

• Auditor's Signature

  Sign