UTIA Safety Office
209 Agricultural Engineering
974-1153
Certification of Hazard Assessment
For
Personal Protective Equipment (PPE)
Company Name: _________________________________________________________
Address: ________________________________________________________________
________________________________________________________________
Workplace Assessed: ______________________________________________________
Name / Job Title:__________________________________________________________
Date(s) of Assessment:____________________________
TYPES OF HAZARDS IN ASSESSED WORKPLACE:
A.____IMPACT / FALLING OBJECT
1.
2.
3.
4.
5.
6.
7.
8.
9.
Are there sources of motion which expose an employee to impact hazards? YES____NO____
List the source(s) of motion:____________________________________________________
Is work performed above or below other workers? YES____NO____
Is it possible for an employee to be struck by a falling object? YES____NO____
Are there any activities generating flying fragments? YES____NO____
List the sources of flying fragments:______________________________________________
___________________________________________________________________________
Do employees carry heavy objects, which could cause injury if dropped? YES____NO____
Is there any movement of personnel that could result in collision with stationary objects?
YES_____ NO_____
Number of this type injury logged in company records for the last 5 years? __________
B._____PENETRATION (sharp objects)
1.
2.
3.
4.
5.
6.
Are there sources of penetration hazards? YES____NO____
List the source(s) of penetration hazard:___________________________________________
Is there scrap metal, nails, wire, staples, or other foot penetration hazards used in this area?
YES____NO____
Are there sharp objects used in process area? YES____NO____
Are there processes where abrasions could occur? YES____NO____
Number of this type injury logged in company records for the last 5 years? __________
C._____COMPRESSION / ROLLING / PINCHING OBJECTS
1.
2.
3.
4.
5.
6.
7.
Are there sources of compression / roll over hazards? YES____NO____
List the source(s) of compression / roll over hazard:__________________________________
Are forklifts used in employee walk areas? YES____NO____
Do employee use manual skid movers? YES____NO____
Are there process hazards, which could crush employee’s hands? YES____NO____
Are there bulk rolls of material or heavy pipes handled by employees? YES_____NO_____
Number of this type injury logged in company records for the last 5 years? __________
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UTIA Safety Office
209 Agricultural Engineering
974-1153
D.____ CHEMICAL EXPOSURE
1.
2.
3.
4.
5.
6.
7.
8.
9.
Are chemicals used in the workplace? YES____NO____
If so, has a Chemical Hazard Analysis been completed? YES____NO____
Are there established Permissible Exposure Limits for each chemical? YES____NO____
Does employee exposure exceed the Permissible Exposure Limit? YES____NO____
Have air monitoring samples been taken to confirm question 4 ? YES____NO____
Will the chemical(s) irritate the skin or eyes? YES____NO____
Is there a splash hazard? YES____NO____
Does the chemical(s) release mists, vapors or gases? YES____NO____
Number of this type injury logged in the company records for the last 5 years?__________
E.____ HIGH or LOW TEMPERATURES (Including possible effects of high-stress)
1.
2.
3.
4.
5.
6.
7.
8.
Are there sources of high temperature in the workplace? YES____NO____
Are there sources of low temperature in the workplace? YES____NO____
Are welding operations performed by employee in the work area? YES____NO____
Are molten metals present? YES____NO____
Are there furnace operations? YES____NO____
Could burn or eye injuries occur from any of the above questions? YES_____ NO_____
Could temperatures adversely affect PPE? YES_____ NO_____
Number of this type injury logged in the company records for the last 5 years? __________
F._____ HARMFUL DUST
1.
2.
3.
4.
5.
Are there sources of harmful dusts? YES____NO____
List the sources of dust hazard(s):________________________________________________
What is the Permissible Exposure Limit of the dust?_________________________________
Is abrasive blasting performed in the work area? YES_____ NO_____
Number of this type injury logged in the company records for the last 5 years?__________
G.____ LIGHT (optical) RADIATION
1.
2.
3.
4.
5.
Is welding, brazing or cutting operations performed in this workplace? YES_____NO_____
Are furnaces or heat-treating performed in this workplace? YES_____NO_____
Are there high intensity light sources? YES_____NO_____
Are lasers used in this workplace? YES_____NO_____
Number of this type injury logged in the company records for the last 5 years? __________
H._____OTHER
1. ELECTRICAL
1. Are there exposed electrical conductors in the work area? YES_____ NO_____
2. Can employees come into contact with these conductors? YES_____ NO_____
2. WORKPLACE LAYOUT HAZARDS: _____________________________________________
_______________________________________________________________________________
3. DROWNING HAZARD:_______ _________________________________________________
_______________________________________________________________________________
4. SLIP, TRIP & FALL HAZARDS: ________________________________________________
______________________________________________________________________________ _
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UTIA Safety Office
209 Agricultural Engineering
974-1153
5. Other Safety Hazards: (list)
_________________________
_________________________
_________________________
____________________________
____________________________
_____________________________
I._____ DO MULTIPLE HAZARDS EXIST IN THIS WORKPLACE?
YES _____ NO_____
The following PPE is required while working in this assessed job / workplace: (check all
that apply)
Hand Protection
_____ Chemical Resistant Gloves
_____ Cut Resistant Gloves
_____ Heat Resistant Gloves
_____ Electrical Protective Gloves
_____ Sleeves
_____ Leather Work Gloves
_____ Other: (list)___________________________________________________________
Head Protection
_____ Hard Hat: Class A____ Class B____ Class C____ Other_____
_____ Welding Hood
_____ Hair Net
_____ Other: (list)___________________________________________________________
Foot Protection
_____ Shoe Covers
_____ Chemical Resistant, steel toed steel shank
_____ Steel toed, steel shank safety shoes
_____ Metatarsel
_____ Other: (list) ___________________________________________________________
Eye and Face Protection
_____ Goggles
_____ Safety Glasses
Side Shield _____
_____ Face Shield
Screen _____
Reflective _____
_____ Shaded Spectacles
Filter lenses rating_____
_____ Welding Helmet
Filter lenses rating_____
_____ Welding Shield
_____ Welding Goggles
Filter lenses rating ______
_____ Other:(list):_____________________
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UTIA Safety Office
209 Agricultural Engineering
974-1153
Hearing Protection
NRR needed_______
_____ Ear Plugs
_____ Ear Muffs
_____ Other (list)________________________________________________________________
Chemical Protective Clothing
_____ Lab Coat
_____ Apron
_____ Smock
_____ Coveralls
made of:_____________________________________
_____ Level A Suit
made of:_____________________________________
_____ Level B Suit
made of:____________________________________
_____ Level C Suit
made of:____________________________________
_____ Rain Suit
Respiratory Protection
_____ Dust Mask rating
_____Type N
_____Type R
_____Type P
Rating _____95 _____99 _____99.99
_____ Air Purifying Respirator
Specify Cartridge:_____________________________________
_____ PAPR
Specify Cartridge:_____________________________________
_____ Supplied Air System
_____ Self Contained Breathing Air (SCBA)
Floatation Devices
_____ Life Vest
_____ Bouyant Work Vest
_____ Other (specify):____________________________________________________________
Traffic Safety Devices
_____ Reflective Vest
_____ Reflective Suit
_____ Other (specify):____________________________________________________________
Other Protective Equipment (specify):
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
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UTIA Safety Office
209 Agricultural Engineering
974-1153
How long can this PPE be worn in the workplace? _______________________________
Can this PPE be reused? YES_____ NO_____ If yes what is the appropriate decontamination procedure?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I certify that the Hazard Assessment required by 29 CFR 1910.132(d) has been performed to assess if
personal protective equipment is needed in the assessed workplace.
Assessors Signature:_____________________________________________
Title:_________________________________________________________
Date:_________________________________________________________
Reference Documents Used
1._________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4._________________________________________________________________________________
5.________________________________________________________________________
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