FORM

Standard: Personal Protective Equipment

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT

Task: Location:
Occupation: Department:
Evaluation Completed By: Date:

Eye and Face Protection

Description of Tasks, Engineering PPE
Type of Hazard Source of Hazard
& Admin. Controls In Place Required

Impact/Flying Objects/Dust Working With, Near or Around:

Flying fragments, objects, large
Chipping Buffing Yes
chips, particles, sand, dirt, dust,
Grinding Sanding No
etc.
Machining Woodworking
Drilling Powered
Chiseling Fastening
Riveting Masonry Work
Sawing Other:

Heat Working With, Near or Around:

Burns
Cutting Pouring Hot Metal Yes
Welding Molten Metals No
Torching Other:
Hot Sparks

Chemical Liquids Working With, Near or Around:

Chemical irritation or burns
Yes
Pouring Mixing
No
Splash Hazards Irritating Mists
Washing/ Irritating Spray
Cleaning Other:

Chemical Gases and Vapors Working With, Near or Around:

Chemical irritation or burns. Compressed Gas System Handling
Yes
Other: _______________
No
Light/Radiation Working With, Near or Around:
Poor vision. Damage to the
Optical Radiation Torch Soldering Yes
eyes.
Cutting Torch Brazing No
Electric Arc Glare
Welding Other:
Gas Welding

Biohazards Working With, Near or Around:

Exposure to infectious material. First Aid/Emergency Care Treatment
Yes
Body Fluids
No
Other:

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Head Protection
Falling Objects Working Under:
Other workers using tools and materials that
Yes
could fall.
No
Machinery or processes which might cause
materials or objects to fall.
Warehouse racking where loose material
loads are handled or stored.
Other:
Overhead Object Interference Working Under or Near:
Conveyor belts carrying material
Yes
Vertical lifts and other elevating work
No
platforms
Other:

Foot Protection
Impact Hazards Working With:
Routine activities where objects
Heavy Packages Heavy Parts/Equip. Yes
heavier than 5 lb. could fall on
Heavy Tools Other: No
feet.
Heavy Objects

Compression Hazards Working With:

Roll-over hazards. High use of carts or pallet trucks
Yes
Handling heavy pipes or logs
No
Drum Handling
Other:

Puncture Protection Working Where There Is:

Puncture to shoe soles.
Nails Scrap Metal Yes
Wire Screws No
Tacks Sharp Objects on
Glass Walking Surfaces
Large Staples Other:

Electrical Hazards Working With or Near:

Electric shock or burns. Exposed Electrical Conductors
Yes
Energized Parts
No
Electrical Switch Gear
Other Exposed Electrical Hazards:
_______________

Chemical Hazards Working With, Near or Around:

Irritation or burns. Splash Hazards from hot or corrosive liquids
Yes
No

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Hand Protection
Chemical Hazards Working With or Handling:
Chemical irritation or burns.
Solvents Toxic Materials Yes
Corrosives Other: ______ No
Skin Irritants

Physical Hazards Working With or Handling:

Cuts, punctures, abrasions, Sharp Objects
Yes
rubbing/friction or lacerations. Sharp Tools
No
Knives
Jagged Objects
Glass
Using, cleaning or dismantling equipment
with sharp points or edges
Abrasive Materials (e.g. sanders)
Other: _______________
Thermal Hazards Working With or Handling:
Burns. Hot Material
Yes
Molten Metal
No
Hot pipes, Steam, or Liquids Welding
Hot Work Activities
Other: _______________
Cryogenic Hazards Working With or In:
Frostbite. Cold Materials
Yes
Cold Weather
No
Other: _______________
Biohazards Contact During:
Exposure to infectious material. First aid/emergency care
Yes
Custodial (Biological Response)
No
Other: _______________
Electrical Hazards Working On or Near:
Electric shock or burn. Energized Circuits of High Voltage (>600v)
Yes
Other: _______________
No

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Respiratory Protection
Inhalation Hazards
Atmospheric Hazards
Working With or Near:
Nuisance Dusts (Chemicals, Wood)
Yes
Fibers (Asbestos, etc.)
No
Mists (Oils, Acids, etc.)
Vapors (Solvents, Gases, etc.)
Fumes (Torch Cutting, Welding, Soldering)
Other: _______________
Working In or Near:
Toxic Atmospheres
Yes
Oxygen-deficient Areas (Below 19.5%
No
Oxygen)
Immediately Dangerous to Life or Health
(IDLH)
Other: _______________

Hearing Protection
Loud Noises Working in Area Exceeding 85 dBA:
Hearing loss. Noise Level From Most Recent Noise
Yes
Survey:
No
Continuous Noise
Impact Noise
Intermittent Noise
Other: _______________

Body Protection
Chemical Hazards Working With or Handling:
Chemical splash exposure.
Solvents Toxic by Skin Yes
Corrosives Absorption No
Irritants Other: ______

Electrical Hazards Working With or Around:

Electric shock or burns. High Voltage (>600v)
Yes
Other: _______________
No
Fire Exposure Working With or Around:
Burns. Fires
Yes
Open Flames
No
Other: _______________
Fall Protection Working from unprotected heights greater
than 4 feet
Yes
Other: _______________
No

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 Personal Protective Equipment – Hazard Assessment Summary
Task: Location:
Occupation: Department:
Evaluation Completed By: Date:

PPE Category PPE Required for this Department

Eye and Face Protection Yes Safety Glasses w/ Side Face Shield Filtered Lenses
No Shields Welders Face Shield Impact Goggles
Chemical Goggles Welding Shields Other: ___________

Head Protection Yes Hard Hat-Class G (Proof Tested to 2,200 Volts)

No Hard Hat-Class E (Proof Tested to 20,000 Volts)
Hard Hat-Class C (No Electrical Protection)
Other: _______________

Foot Protection Yes Safety Shoes Electrical Hazard Soles: Material:

No Boots Leather Neoprene
Metatarsal Guards Rubber PVC
Boot Cover Other: ____________ Poly/Nylon

Hand Protection Yes Gloves: PVC Heat Resistant

No Wrist Length Nitrile Welding
Elbow Length PVA Cold Resistant
Shoulder Length Latex Electrical Resistant
Chemical Resistant Abrasion Resistant Anti-Static
Butyl Cut Resistant Other: ___________
Neoprene Puncture Resistant

Respiratory Protection Yes Air Purifying Airline Full-Face

No Dust PAPR Canister
Mist SCBA Cartridge
Fume Half-Face Other: ___________

Hearing Protection Yes Earmuffs Min. Noise Reduction Rating

No Earplugs Other: _______________

Body Protection Yes Apron Coveralls Insulating Covers

No Jacket/Coat Insulating Blankets Other: ___________
Long Sleeves

Fall Protection Yes

No

Comments:

_____________________ __________ __________________________ _________

Supervisor Date Environmental Safety Officer Date

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