Site Specific Job Hazard Assessment Form Name of project: __________________________________ Company: _________________________ EYES Work Activities Work activities, such as: abrasive blasting chopping cutting drilling welding punch press operations other: _______________________________ FACE Work activities, such as: cleaning siphoning painting other________________________________ Completed by:___________________________ Possible Health Hazards Date: Hazard Control / Injury Prevention Methods Work-related exposure to: airborne dust sanding flying particles blood splashes hazardous liquid chemicals intense light other: _______________________ Can hazard be eliminated without the use of PPE? Yes No sawing If no,grinding use: Safety hammering glasses Safety goggles Shading/Filter (# ) Welding shield Other: _______________________________ Work-related exposure to: hazardous liquid chemicals extreme heat/cold welding potential irritants: -______________ mixing other: _______________________ Can hazard be eliminated without the use of PPE? Yes foundry No work If no, use: Face pouring shield molten Shading/Filter (# ) Welding shield Other: _________________________________ HEAD Work activities, such as: building maintenance confined space operations construction electrical wiring walking/working under catwalks walking/working under conveyor belts walking/working under crane loads utility work other: _______________________________ Work-related exposure to: Can hazard be eliminated without the use of PPE? beams Yes No pipes exposed electrical wiring/ components If no, use: falling objects Protective Helmet machine parts Type A (low voltage) other: _______________________ Type B (high voltage) Type C Bump cap (not ANSI-approved) Hair net or soft cap Other: ________________________________ HANDS/ARMS Work activities, such as: grinding welding working with glass using computers using knives other: _______________________________ Work-related exposure material to: handling blood sawing irritating chemicals hammering tools or materials that could scrape, bruise, or cut extreme heat/cold other: ________________________ Can hazard be eliminated sanding without the use of PPE? Yes No Work-related exposure to: Can hazard be eliminated without the use of PPE? Yes No If no, use: Gloves Chemical resistance Liquid/leak resistance Temperature resistance Abrasion/cut resistance Slip resistance Protective sleeves Other: _______________________________ FEET/LEGS Work activities, such as: building maintenance construction demolition plumbing trenching use of highly flammable materials welding other: ______________________________ BODY/SKIN Work activities such as: battery charging fiberglass installation irritating chemicals sawing other: _______________________________ explosive atmospheres explosives If no, use: exposed electrical wiring /components Safety shoes or boots heavy equipment Toe protection slippery surfaces Electrical protection Heat/cold protection tools Puncture resistance Chemical resistance other: _______________________ Anti-slip soles Leggings or chaps Foot-Leg guards Other: ________________________________ Work-related exposure to: chemical splashes extreme heat/cold sharp or rough edges other: _______________________ Can hazard be eliminated without the use of PPE? Yes No If no, use: Vest, Jacket Coveralls, Body suit Raingear Apron Welding leathers Abrasion/cut resistance Other: ________________________________ Body/Whole Work activities such as: Work-related exposure to: building maintenance construction utility work other: ______________________________ working from heights of 10’ft or more working near water other: ________________________ Can hazard be eliminated without the use of PPE? Yes No If no, use: Fall Arrest/Restraint: Type:______________ PFD: Type: _________________________ Other: _________________________________ LUNGS/RESPIRATORY Work activities such as: Work-related exposure to: cleaning pouring mixing sawing painting fiberglass installation compressed air or gas operations other: ________________________ irritating dust or particulate irritating or toxic gas/vapor other: ______________________ Can hazard be eliminated without the use of PPE? Yes No If no, use: Respirator* *Please note in the space below the appropriate type, including manufacturer model & class of respirator being used for this job. EARS/HEARING Work activities such as: generator ventilation fans motors sanding pneumatic equipment punch or brake presses other:__________________ Work-related exposure to: grinding machining routers sawing loud noises loud work environment noisy machines/tools punch or brake presses other: ____________________ Can hazard be eliminated without the use of PPE? Yes No If no, select appropriate protection grade level for noise: Ear Plugs Ear Muffs Other ________________________ Additional Notes:
