PPE Hazard Assessment & Certification Form
Work Site:
Work Phase:
Work Area(s):
Job/Task(s):
EYES / FACE
Work Site exposure(s):
☐ Flying particles
☐ Airborne dusts/aerosols
☐ Hazardous liquids/chemicals
☐ Intense light
☐ Blood/Body fluid splashes
☐ Extreme environmental temps
☐ Other:
HEAD
Work Site exposure(s):
☐ Falling Objects
☐ Overhead projections
☐ Construction equipment
☐ Machine parts
☐ Electrical wiring or components
☐ Extreme environmental temps
☐ Other:
HANDS / ARMS
Work Site exposure(s):
☐ Hazardous materials
☐ Sharp projections/surfaces
☐ Moving machinery/Pinch points
☐ Handling tool(s)
☐ Extreme surface temps
☐ Other:
FEET / LEGS
Work Site exposure(s):
☐ Hazardous materials
☐ Heavy falling or rolling objects
☐ Construction equipment
☐ Slippery surfaces
☐ Electrical wiring or components
☐ Handling tool(s)
☐ Extreme environmental temps
☐ Other:
BODY / SKIN
Work Site exposure(s):
☐ Hazardous materials
☐ Sharp projections / surfaces
☐ Extreme environmental temps
☐ Other:
FALL PROTECTION
Work Site exposure(s):
☐ Unprotected height > 4 feet
☐ Leading edge
☐ Other:
LUNGS / EARS
Work Site exposure(s):
☐ Airborne dusts/aerosols
☐ Toxic gas/vapors
☐ Oxygen displacement
☐ Respiratory sensitizers
☐ Loud operating equipment
☐ Oto-toxicants
☐ Other:
Assessment Conducted by:
Date of Assessment:
PPE Selection by:
Effective Date:
Negligible Hazard: ☐YES ☐NO
PPE necessary to reduce exposure(s):
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Safety glasses
☐ Safety goggles
☐ Face shield
☐ Shading/Filtering
☐ Welding shield
☐ Cold weather safety goggles
☐ Other:
Negligible Hazard: ☐YES ☐NO
PPE necessary to reduce exposure(s):
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Protective Hard-hat
☐ Type 1
☐ Class E ☐ Class G ☐ Class C
☐ Type 2
☐ Class E ☐ Class G ☐ Class C
☐ Cold weather head apparel
☐ Other:
Negligible Hazard: ☐YES ☐NO
PPE necessary to reduce exposure(s):
☐ Gloves
☐ Cut rated
☐ Chemical resistant
☐ Long Gauntlet
☐ Long sleeves
☐ Other:
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Impact resistant
☐ Temperature resistant
☐ Insulated
Negligible Hazard: ☐YES ☐NO
Required PPE to reduce exposure(s):
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Protective footwear
☐ Safety toe
☐ Metatarsal protection
☐ Chemical resistance
☐ Anti-slip soles
☐ Tall shaft (>6 inches)
☐ Insulated/Waterproof
☐ Insulated pants or undergarment(s)
☐ Other:
Negligible Hazard: ☐YES ☐NO
Required PPE to reduce exposure(s):
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Flame resistant (FR)
☐ Abrasion/Cut resistant
☐ Chemical resistance
☐ Raingear
☐ Welding leathers
☐ Disposable coveralls
☐ Insulated jacket - PRF CAT: ☐3 ☐4 ☐5
☐ Other:
Negligible Hazard: ☐YES ☐NO
Required PPE to reduce exposure(s):
☐ Fall arrest
☐ Leading edge lanyard
☐ Other:
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Fall restraint
Negligible Hazard: ☐YES ☐NO
Required PPE to reduce exposure(s):
Hazard eliminated w/o PPE: ☐YES ☐NO
Notes:
☐ Air-purifying respirator
Cartridge: ☐ Particulate ☐ Gas/Vapor ☐ Combo
☐Supplied-air respirator
☐ Hearing protection
☐ Other:
PPE Hazard Assessment & Certification Form
Personal Protective Equipment Determination:
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Additional Notes:
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Signatures:
Assessment Conducted by:
Assessment Certification:
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Date:
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Title:
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Date:
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Title:
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