PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing

Employee Name: Dept / Work areas(s):

Job/task(s): Signature Date of
Assessment:
Assessment
Conducted by:

Work Activities EYES Personal Protective Equipment

Abrasive Blasting Janitorial Work-Related Exposures Can hazard be eliminated Yes
Chopping Landscape without the use of PPE? No
Cutting maintenance Airborne dust
Drilling Sanding Flying particles If no, use: Side shields
Grinding Sawing Blood splashes Safety glasses Dust tight goggles
Hammering Welding Hazardous liquid chemicals Safety goggles Welding shield
Other ____________ Intense light Shading/filter # _______
Other _________________ Other _______________

Work Activities FACE Personal Protective Equipment

Food prep Solvent cleaning Work-Related Exposures Can hazard be eliminated Yes
Janitorial Welding without the use of PPE? No
Mixing Other _____________ Extreme heat/cold
Painting Hazardous liquid chemicals If no, use: Welding shield
Potential irritants ________ Face shield
Other __________________ Shading/filter # _______
Other _______________

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing

HEAD

Work Activities Work-Related Exposures Personal Protective Equipment

Building maintenance Walking/working Beams Can hazard be eliminated Yes
Confined space under catwalk Pipes without the use of PPE? No
operations Walking/working Exposed electrical wiring
Construction under crane loads or components If no, use: Hard hat
Road work Utility work Falling objects Protective Helmet: Hair net
Electrical wiring Other Machine parts Soft cap
________________ Other ________________ Flying/falling objects, no Other _________
electrical contact
Electrical contact
(<600 V)
Electrical contact
(>600V)
Bump Cap (not ANSI approved)

Work Activities HANDS - ARMS Personal Protective Equipment

Building maintenance Knife use Work-Related Exposures Can hazard be eliminated Yes
Computer use Landscape without the use of PPE? No
Food Preparation maintenance Biological hazards
Grinding Material Handling (poison oak, insects, etc.) If no, use: Protective sleeves
Hammering Sanding Blood Gloves: Other _________
Health Care Services Sawing Extreme heat/cold
Janitorial Welding Irritating chemicals Chemical resistance
Working with glass Scrape, bruise, or cut by Liquid/leak resistance
Other ____________ tools or materials Temperature resistance
Other _______________ Abrasion/cut resistance
Slip resistance

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing

FEET - LEGS

Work Activities Work-Related Exposures Personal Protective Equipment

Building maintenance Plumbing Explosive atmospheres Can hazard be eliminated Yes
Construction Trenching Exposed electrical wiring without the use of PPE? No
Road work Use of flammable or components
Demolition materials Heavy equipment If no, use: Leggings
Janitorial Welding Slippery surfaces Safety shoes or boots Chaps
Landscape Other _____________ Tools Foot-leg guards
maintenance Other _______________ Anti-slip soles Other _________
Chemical resistant
Electrical protection
Heat/cold protection
Metatarsal protection
Puncture resistance
Toe Protection

Work Activities BODY - SKIN Personal Protective Equipment

Food preparation Solvent cleaning Work-Related Exposures Can hazard be eliminated Yes
Battery charging Sawing without the use of PPE? No
Other _____________ Chemical splashes
Extreme heat/cold If no, use: Rain gear
Sharp or rough edges Apron Welding leathers
Other _______________ Body suit Other _________
Coveralls
Vest, jacket

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing

RESPIRATORY PROTECTION

Work Activities Work-Related Exposures Personal Protective Equipment

Sanding/grinding Leaf blowing Nuisance dust (non-hazardous) Can hazard be eliminated Yes
Painting Solvent cleaning Hazardous dust/particulates without the use of PPE? No
Soldering/welding Sawing/milling Vapors
Chemical handling Other _____________ Metal fumes If no, is voluntary use of N95 or Yes
Caustic handling Other _____________ R95 filtering facepiece possible : No
Sweeping/dusting
Pesticides/fertilizers If no, contact [email protected] for respirator options
including air purifying and supplied air respirators.

Work Activities HEARING PROTECTION Personal Protective Equipment

Power tools Equipment chase access Work-Related Exposures Can hazard be eliminated Yes
Pneumatic tools Landscape equipment without the use of PPE? No
Animal Husbandry Other _____________ Continuous noise
CUP Access Intermittent loud noises If no, use: Earmuffs
Other _______________ Earplugs Custom earplugs
Ear canals
Headband

Contact [email protected] for noise related
concerns or assessments.

Posted 4/3/2012