TVA - Workplace Hazard Assessment and PPE Selection

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Assessment Date:

  Date

• Task, Job Function or Location:

• For each section listed below identify all of the hazards associated with the task, job function or location.

SECTION 1 - EYE HAZARD (29CFR 1910.133)

• Impact

  Yes

  No

  N/A

• Penetration

  Yes

  No

  N/A

• Chemical

  Yes

  No

  N/A

• Heat

  Yes

  No

  N/A

• Light / Radiation

  Yes

  No

  N/A

• ARC Flash

  Yes

  No

  N/A

• DESCRIBE THE SPECIFIC HAZARD(s) - Section 1

• DESCRIBE THE REQUIRED PPE ASSOCIATED - Section 1

SECTION 2 - HEAD HAZARD (29CFR 1910.135)

• Burn

  Yes

  No

  N/A

• Electric Shock

  Yes

  No

  N/A

• Impact

  Yes

  No

  N/A

• Penetration

  Yes

  No

  N/A

• Chemicals

  Yes

  No

  N/A

• Noise

  Yes

  No

  N/A

• DESCRIBE THE SPECIFIC HAZARD(s) - Section 2

• DESCRIBE THE REQUIRED PPE ASSOCIATED - Section 2

• Specific Head Protection required:

  None head protection required

  Class A

  Class

  Class C

• Specific Hearing Protection required:

  No hearing protection required (<85db)

  Ear Plugs

  Ear Muffs

  DOUBLE Hearing Protection Required

SECTION 3 - INDUSTRIAL WORK CLOTHING

• DESCRIBE THE SPECIFIC HAZARD(s) - Section 3

• DESCRIBE THE REQUIRED PPE ASSOCIATED - Section 3

SECTION 4 - FOOT HAZARDS (29CFR 1910.136)

• Chemical

  Yes

  No

  N/A

• Compression

  Yes

  No

  N/A

• Impact

  Yes

  No

  N/A

• Puncture

  Yes

  No

  N/A

• Penetration

  Yes

  No

  N/A

• Electrical

  Yes

  No

  N/A

• DESCRIBE THE SPECIFIC HAZARD(s) - Section 4

• DESCRIBE THE REQUIRED PPE ASSOCIATED - Section 4

SECTION 5 - HAND HAZARD (29CFR 1910.138)

• Burn (thermal, electrical, radiation)

  Yes

  No

  N/A

• Electrical Shock

  Yes

  No

  N/A

• Impact

  Yes

  No

  N/A

• Penetration

  Yes

  No

  N/A

• Chemical

  Yes

  No

  N/A

• DESCRIBE THE SPECIFIC HAZARD(s) - Section 5

• DESCRIBE THE REQUIRED PPE ASSOCIATED - Section 5

SECTION 6 - AIRBORNE HAZARDS (29CFR 1910.134)

• IDLH (Immediately Dangerous to Life & Health)

  Yes

  No

  N/A

• Nuisance Dust

  Yes

  No

  N/A

• Fumes (particulate & smoke)

  Yes

  No

  N/A

• Gas (i.e chlorine, ammonia)

  Yes

  No

  N/A

• Vapor (I.e. paint, gasoline, MEK)

  Yes

  No

  N/A

• Aerosol Mist (i.e. paint spraying)

  Yes

  No

  N/A

• DESCRIBE THE SPECIFIC HAZARD(s) - Section 6

• DESCRIBE THE REQUIRED PPE ASSOCIATED - Section 6

• Minimum Protection Factor Required:

  Select None 10 50 100 1,000 5,000 10,000

  • None
  • 10
  • 50
  • 100
  • 1,000
  • 5,000
  • 10,000

• Specific Type Respirator Required:

  Select None required Half Face - Air Purifying Respirator Full Face - Air Purifying Respirator Full Face PAPR Supplies Air Respirator - Demand mode Supplies Air Respirator - Continuous Flow mode Supplies Air Respirator - Pressure-demand mode SCBA - Demand mode SCBA - Pressure-demand mode

  • None required
  • Half Face - Air Purifying Respirator
  • Full Face - Air Purifying Respirator
  • Full Face PAPR
  • Supplies Air Respirator - Demand mode
  • Supplies Air Respirator - Continuous Flow mode
  • Supplies Air Respirator - Pressure-demand mode
  • SCBA - Demand mode
  • SCBA - Pressure-demand mode

• This certifies that a workplace hazard assessment has been performed for the hazards described and required personal protective equipment measures established

• CERTIFIED BY:

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