UW-Stout
Personal Protective Equipment (PPE)
Hazard Assessment Certification
Project:
Job Classification:
Part of Body
Hands
Hazard
Required PPE
PPE
Penetration-sharp objects
Penetration-animal bites
Penetration-rough objects
Chemical(s)
Extreme cold
Extreme heat
Blood
Electrical shock
Vibration-power tools
Other
A. Leather/cut resistant gloves
B. General purpose work gloves
C. Chemical resistant gloves;
Type _
______________
D. Insulated gloves
E. Heat/flame resistant gloves
F. Nitrile gloves
G. Insulated rubber gloves
Type _
___________
H. Cotton, leather or antivibration gloves
Impact-flying objects,
chips, sand or dirt
Nuisance dust
UV light-welding, cutting,
torch brazing or soldering
Chemical-splashing liquid
Chemical-irritating mists
Hot sparks-grinding
Splashing molten metal
Glare/High Intensity lights
Laser Operations
Other
I.
J.
K.
L.
M.
Notes
Eyes and
Face
N.
O.
P.
Q.
R.
Safety glasses w/side shields
Glasses/goggles w/face shield
Impact goggles
Welding goggles
Welding helmet/shield
w/safety glasses & side shields
Chemical goggles & face shield
Chemical splash goggles
Safety goggles w/face shield
Shaded safety glasses
Laser spectacles or goggles
Notes
Ears
Exposure to noise levels
( 85 dBA 8-hour TWA)
Exposure to sparks
S. Ear muffs, plugs or ear caps
T. Full Face Shield
Other
Notes
Rev. 6/11/2010
1
Part of Body
Hazard
Struck by falling object
Struck against fixed object
Electrical-contact with
exposed wires/conductors
Other
Head
Required PPE
PPE
U. Hard hat/cap Class A (Impact
and electrical < 2,200 volts)
V. Hard hat/cap Class B (Impact
and Electrical < 20,000 volts)
W. Hard hat/cap Class C (Impact
Only)
Notes
Respiratory
System
Nuisance dust/mist
Welding fumes
X.
Y.
Asbestos
Lead
Z.
AA.
Pesticides
Paint spray
Organic vapors
Acid gases
Oxygen deficient/toxic
or IDLH atmosphere
Other
BB.
CC.
DD.
EE.
Disposable dust/mist mask
Welding respirator or point
source ventilation
Respirator w/HEPA filter
Respirator w/pesticide
cartridges
Respirator w/paint spray
cartridges
Respirator w/organic
cartridges
Respirator w/acid gas
cartridges
SCBA or Type C airline
respirator
Notes
Feet
Impact-heavy objects
Compression-rolling or
pinching objects/vehicles
Slippery or wet surface
Penetration-sharp objects
Penetration-chemical
Splashing-chemical
Exposure to extreme cold
Other
FF.
GG.
HH.
II.
JJ.
KK.
LL.
Steel toe safety shoes
Leather boots or safety
shoes w/metatarsal
guards
Slip resistant soles
Puncture resistant soles
Chemical resistant
boots/covers
Rubber boots/closed top
shoes
Insulated boots or shoes
Notes
Rev. 6/11/2010
2
Part of Body
Body
Hazard
Impact-flying objects
Moving vehicles
Penetration-sharp objects
Electrical-static discharge
Hot metal or sparks
Exposure to extreme cold
Unprotected elevated
walking/working surface
Chemical(s):
Other
Required PPE
PPE
MM.
NN.
OO.
PP.
QQ.
RR.
SS.
TT.
Long sleeves/ apron/ coat
Traffic vest
Cut-resistant sleeves,
wristlets
Static control
coats/coveralls
Flame-resistant jacket/
pants
Lab coat or apron/sleeves
Insulated jacket, hood
Body harness and lanyard
Notes
For Physical Plant Employees:
 The hazards above have been noted. The hazards identified are those expected under normal
working conditions. If other hazards are encountered, employees should stop work, evacuate
the area, and notify their supervisor.
 PPE is provided in the supply cage. Please see your supervisor with any other questions.
CERTIFICATION: I certify that I personally performed the above Hazard Assessment on
the date indicated. This document is a Certification of the Hazard Assessment.
Safety and Risk Management
Name:
Signature:
Date:
Signature:
Date:
Department:
Supervisor
Name:
EMPLOYEE CERTIFICATION: The information on this form has been reviewed with me. (The employee's signature
does not necessarily indicate agreement, but attests to the fact the employee has received the information)
Employee
Name:
Rev. 6/11/2010
Signature:
Date:
3