Personal Protective Equipment (PPE)
Hazard Assessment
Laboratory (Building Name and Room Number): ______________________ PI Responsible for the Laboratory: _________________________________________
Description of the Task/Lab Being Evaluated: _______________________________________________________________________________________________
Name of Person Completing PPE Assessment: ______________________________________________________________________________________________
HAZARD
Check box under
hazard if hazard does
not exist in lab.
BODY PART POTENTIALLY
AFFECTED
Eyes
Face
Fingers /
Hands
Arms
Legs
Foot
Whole Body /
Torso
Respiratory
Head
Ears
Page 1 of 3
Other Hazards
Specify:
_____________
Parasites
Fungi
Viruses
Bacteria
Gases, Vapors
Splashes, Sprays
Other
Human Tissue or Body
Fluids
BIOLOGICAL
Liquid
Fumes/Mist
Particles –
Dust, Fibers
Particulate
Noise
Ionizing
Non-ionizing
Radiation
Electrical
Cold
Heat / Fire / Flash
Fire
Thermal
Slips and Falls or
Falls from Heights
Vibration
Stabs, Cuts
Blows, Cuts,
Impact Crushing
Mechanical
CHEMICAL
Immersion
PHYSICAL
Personal Protective Equipment (PPE) Requirements
Laboratory (Building Name and Room Number): ________________ PI Name:______________________________
Default PPE requirements when inside a laboratory with hazards (chemical, mechanical, physical) unless otherwise noted include:
Safety Glasses, Closed-toe shoes w/ substantial soles, Pants or Skirt to the Ankles, and Shirt with coverage equal to or greater than a TShirt.
 Check applicable PPE to protect affected Body Part(s) listed on Page 1 of this document and engineering controls that mitigate the hazard.
If you have questions, contact RMS at 1-5037
Personal Protective Equipment (PPE)
EYE and FACE PROTECTION
Engineering Controls that mitigate hazard
 Safety Glasses w/ side-shields
Gas Cabinet
 Chemical Goggles
Glove Box
 Welding Goggles or Helmet
EYE AND FACE
Other Controls
Biosafety Cabinet
 Laser Glasses or Goggles –
Chemicals in approved storage cabinet (used
infrequently). Specific PPE required when used.
Optical Density #________
Other Specify:
 Face-shield – Chemical Splash
 Welding Face-shield –
Shade #_________
BODY & TORSO
BODY and TORSO PROTECTION
Engineering Controls that mitigate hazard
 Disposable lab coat
Gas Cabinet
 General Purpose lab coat
Glove Box
 Flame-resistant lab coat
Chemicals in approved storage cabinet (used
infrquently). Specific PPE required when used.
 Chemical Resistant Apron – Specify Type:_
 General Purpose Full Body Suit (Tyvek®)
 Fall Protection Harness / Lanyard (for fall from height hazard)
Other Specify:
 Specify Other:
HAND/FINGERS and ARM PROTECTION
Engineering Controls that mitigate hazard
HAND/FINGER & ARM
 Chemical Resistant Gloves: □ Butyl □ Latex □ Natural Rubber
□ Neoprene □ Nitrile
□ PVC
□ Vinyl □ Teflon/Vita
□ Specify Other:
 Cut / Puncture Resistant Gloves:
□ Leather
□ Kevlar
□ Specify Other:____________________
 Cotton Glove – Heavy; General Purpose
Other Specify:
 Thermal Gloves: □ Heat □ Cryogenic
 Low Voltage Gloves – Class
 Chemical Resistant Sleeves – Specify Type:
 Specify Other
FOOT and LEG PROTECTION
FOOT & LEG
Chemicals in approved storage cabinet (used
infrequently). Specific PPE required when used.
 Steel-toed Safety Shoes
 Slip-resistant
Specify:
□ Shoes
Engineering Controls that mitigate hazard
Chemical Resistant Footwear – Specify:
□ Boots  Chemical Resistant Pants –
Chemicals in approved storage cabinet (used
infrequently). Specific PPE required when used.
Other Specify:
 Specify Other:
Page 2 of 3
Personal Protective Equipment
(PPE)
RESPIRATORY PROTECTION (Requires medical evaluation and fit
testing – contact RMS)
 APR Half-face Respirator
Other Controls
Engineering Controls that mitigate hazard
Gas Cabinet
Facepiece Type:_______________
Glove Box
Cartridge Type:
RESPIRATORY
 APR Full-face Respirator
Cartridge Type:
___________________
Biosafety Cabinet
Lab Hood
Facepiece Type:_______________
___________________
Chemicals in approved storage cabinet (used
infrequently). Specific PPE required when used.
Other Specify:
 PAP Respirator □ Hood or □ Facepiece Type:
Cartridge Type:
EAR
HEAD
 Disposable Dust Mask (Mandatory Use)
HEAD PROTECTION
Specify Engineering Controls that mitigate hazard
 Hard Hat – Type I for falling objects or Type II for side impacts.
Recommend Class E rating for electrical protection.
EAR PROTECTION
Specify Engineering Controls that mitigate hazard
 Ear Plugs or Ear Muffs
 Combination / Dual Hearing Protection
CERTIFICATION
I certify to the best of my knowledge that the personal protective equipment requirements have been reviewed and
prescribed to protect against the hazards identified on Page 1 of this document.
Signature:_________________________________________
Date:__________________________________
This certification is required by 29 CFR 1910.132(d)(2)
Relaxed PPE Approval Signatures:
PI Signature:_________________________________________
Date:__________________________________
Dept/Unit :__________________________________________
Date:__________________________________
RMS :______________________________________________
Date:__________________________________
Page 3 of 3