Ppe hazard assessment certification form



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PPE hazard assessment certification form
Name of workplace*_______________________ Assessment conducted by* ________________

Workplace address* ______________________________ Date of assessment* ____/____/____

Work areas _______________________________ Job or task** _________________________

*Required for certifying the hazard assessment. **Use a separate sheet for each job, task, or work area.





Eyes

Work activities such as:
□ Abrasive blasting

□ Chopping

□ Cutting

□ Drilling

□ Welding

Punch press operations

□ Sanding

□ Sawing


□ Grinding

□ Hammering

□ Other: ___________________



Work-related exposure to:
□ Airborne dust

□ Flying particles

□ Blood splashes

Hazardous liquid chemicals

□ Intense light

□ Other: ______________________


­­­­­­­­­­­­­

Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:
□ Safety glasses

□ Safety goggles

□ Shading/filter # _______

□ Welding shield

□ Side shields

Dust-tight goggles

□ Other ____________________


Face

Work activities such as:
□ Cleaning

□ Cooking

□ Siphoning

□ Painting

□ Dip tank operations

□ Foundry work

□ Welding

□ Mixing


Pouring molten metal

□ Other: ­­­­­­­­­­­­­­­­__________________




Work-related exposure to:
□ Hazardous liquid chemicals

□ Extreme heat or cold

□ Potential irritants: ­­­­____________

­­­­­­­­­­­­­­­­­­­­□ Other: ______________________



Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:
□ Face shield

□ Shading/filter # ________

□ Welding shield

□ Other: ___________________



Head

Work activities such as:
□ Building maintenance

Confined space operations

□ Construction

□ Electrical wiring

□ Walking/working under catwalks

□ Walking/working under conveyor

belts.

□ Walking/working under crane



loads

□ Utility work

□ Other: ­­­­­­­­­­­__________________


Work-related exposure to:
□ Beams

□ Pipes


Exposed electrical wiring or

components

□ Falling objects

□ Machine parts

□ Other: _________________


Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:

□ Protective helmet

□ Type A (low voltage)

□ Type B (high voltage)

□ Type C

□ Bump cap (not ANSI-approved)

□ Hair net or soft cap

Other: _____________________




Hands/arms

Work activities such as:
□ Baking

□ Cooking

□ Grinding

□ Welding

Working with glass

□ Using computers

□ Using knives

□ Dental and health care services

□ Material handling

□ Sanding

□ Sawing

□ Hammering

□ Other: __________________


Work-related exposure to:
□ Blood

□ Irritating chemicals

□ Tools or materials that could

scrape, bruise, or cut

□ Extreme heat or cold

□ Other: ____________________




Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:
□ Gloves

□ Chemical resistance

□ Liquid/leak resistance

□ Temperature resistance

□ Abrasion/cut resistance

Slip resistance

□ Protective sleeves

□ Other: __________________



Feet/legs

Work activities such as:
□ Building maintenance

Construction

□ Demolition

□ Food processing

□ Foundry work

□ Logging

Plumbing

□ Trenching

□ Use of highly flammable

material


□ Welding

Other: __________________




Work-related exposure to:
□ Explosive atmospheres

□ Explosives

□ Exposed electrical wiring or

components

Heavy equipment

□ Slippery surfaces

□ Tools

□ Other: ____________________



Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:
□ Safety shoes or boots

□ Toe protection

□ Metatarsal protection

□ Electrical protection

□ Heat/cold protection

□ Puncture resistance

□ Chemical resistance

□ Anti-slip soles

□ Leggings or chaps

□ Foot-leg guards

□ Other: _________________


Body/skin

Work activities such as:
□ Baking or frying

Battery charging

□ Dip tank operations

□ Fiberglass installation

□ Irritating chemicals

□ Sawing


□ Other: _________________



Work-related exposure to:
□ Chemical splashes

□ Extreme heat or cold

□ Sharp or rough edges

□ Other: ___________________



Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:
□ Vest, jacket

□ Coveralls, body suit

□ Raingear

□ Apron


□ Welding leathers

□ Abrasion/cut resistance

□ Other: __________________


Whole body

Work activities such as:
□ Building maintenance

□ Construction

□ Logging

□ Utility work

□ Other: __________________


Work-related exposure to:
□ Working from heights of 10 feet or

more


□ Working near water

□ Other: ____________________



Can hazard be eliminated without the use of PPE?
□ Yes □ No
If no, use:
□ Fall arrest/restraint

Type: __________________

□ PFD

Type: ___________________



□ Other: ___________________


Lungs/respiratory

Work activities such as:
□ Cleaning

□ Mixing


Painting

□ Fiberglass installation

□ Compressed air or gas

operations

□ Other: __________________


Work-related exposure to:
□ Irritating dust or particulate

□ Irritating or toxic gas or vapor

□ Other: __________________


Can hazard be eliminated without the use of PPE?
□ Yes □ No



Ears/hearing

Work activities such as:
□ Generator

Ventilation fans

□ Motors

□ Sanding

□ Pneumatic equipment

□ Punch or brake presses

□ Use of conveyors

□ Grinding

□ Machining

□ Routers

□ Sawing

□ Others: ________________




Work-related exposure to:
□ Loud noises

Loud work environment

□ Noisy machines/tools

□ Punch or brake presses



□ Other: ___________________

Can hazard be eliminated without the use of PPE?
□ Yes □ No




Source: “Personal Protective Equipment (PPE) Guide,” State of Washington Department of Labor and Industries.


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