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):
Assessment
Conducted by:
Date of
Assessment:
Signature
EYES
Work Activities
Abrasive Blasting
Chopping
Cutting
Drilling
Grinding
Hammering
Janitorial
Landscape
maintenance
Sanding
Sawing
Welding
Other ____________
Work-Related Exposures
Airborne dust
Flying particles
Blood splashes
Hazardous liquid chemicals
Intense light
Other _________________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
Yes
No
If no, use:
Safety glasses
Safety goggles
Shading/filter # _______
Other _______________
Side shields
Dust tight goggles
Welding shield
FACE
Work Activities
Food prep
Janitorial
Mixing
Painting
Solvent cleaning
Welding
Other _____________
Work-Related Exposures
Extreme heat/cold
Hazardous liquid chemicals
Potential irritants ________
Other __________________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
If no, use:
Face shield
Shading/filter # _______
Other _______________
Yes
No
Welding shield
PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing
HEAD
Work Activities
Building maintenance
Confined space
operations
Construction
Road work
Electrical wiring
Walking/working
under catwalk
Walking/working
under crane loads
Utility work
Other
________________
Work-Related Exposures
Beams
Pipes
Exposed electrical wiring
or components
Falling objects
Machine parts
Other ________________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
If no, use:
Protective Helmet:
Flying/falling objects, no
electrical contact
Electrical contact
(<600 V)
Electrical contact
(>600V)
Bump Cap (not ANSI approved)
Yes
No
Hard hat
Hair net
Soft cap
Other _________
HANDS - ARMS
Work Activities
Building maintenance
Knife use
Computer use
Landscape
Food Preparation
maintenance
Grinding
Material Handling
Hammering
Sanding
Health Care Services
Sawing
Janitorial
Welding
Working with glass
Other ____________
Work-Related Exposures
Biological hazards
(poison oak, insects, etc.)
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
Blood
Extreme heat/cold
Irritating chemicals
Scrape, bruise, or cut by
tools or materials
Other _______________
Yes
No
If no, use:
Gloves:
Chemical resistance
Liquid/leak resistance
Temperature resistance
Abrasion/cut resistance
Slip resistance
Protective sleeves
Other _________
PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing
FEET - LEGS
Work Activities
Building maintenance
Construction
Road work
Demolition
Janitorial
Landscape
maintenance
Plumbing
Trenching
Use of flammable
materials
Welding
Other _____________
Work-Related Exposures
Explosive atmospheres
Exposed electrical wiring
or components
Heavy equipment
Slippery surfaces
Tools
Other _______________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
If no, use:
Safety shoes or boots
Anti-slip soles
Chemical resistant
Electrical protection
Heat/cold protection
Metatarsal protection
Puncture resistance
Toe Protection
Yes
No
Leggings
Chaps
Foot-leg guards
Other _________
BODY - SKIN
Work Activities
Food preparation
Battery charging
Solvent cleaning
Sawing
Other _____________
Work-Related Exposures
Chemical splashes
Extreme heat/cold
Sharp or rough edges
Other _______________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
Yes
No
If no, use:
Apron
Body suit
Coveralls
Vest, jacket
Rain gear
Welding leathers
Other _________
PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
Eyes ▪ Face ▪ Head ▪ Hands-Arms ▪ Feet-Legs ▪ Body-Skin ▪ Respiratory ▪ Hearing
RESPIRATORY PROTECTION
Work Activities
Sanding/grinding
Painting
Soldering/welding
Chemical handling
Caustic handling
Sweeping/dusting
Pesticides/fertilizers
Leaf blowing
Solvent cleaning
Sawing/milling
Other _____________
Work-Related Exposures
Nuisance dust (non-hazardous)
Hazardous dust/particulates
Vapors
Metal fumes
Other _____________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
Yes
No
If no, is voluntary use of N95 or
R95 filtering facepiece possible :
Yes
No
If no, contact ehsih@ucsd.edu for respirator options
including air purifying and supplied air respirators.
HEARING PROTECTION
Work Activities
Power tools
Pneumatic tools
Animal Husbandry
CUP Access
Equipment chase access
Landscape equipment
Other _____________
Work-Related Exposures
Continuous noise
Intermittent loud noises
Other _______________
Personal Protective Equipment
Can hazard be eliminated
without the use of PPE?
Yes
No
If no, use:
Earplugs
Ear canals
Headband
Earmuffs
Custom earplugs
Contact ehsih@ucsd.edu for noise related
concerns or assessments.
Posted 4/3/2012