Employee Name/Title: Assessment Conducted by: Department: Date of Assessment: Job/Task(s): Effective Start Date: EYES/FACE Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: PPE required to manage hazard: Comments: airborne dust Safety glasses flying particles Safety goggles hazardous liquids/chemicals Face Shield intense light Shading/Filter (# ) blood splashes Welding shield other: Other: HEAD Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: PPE required to manage hazard: Comments: beams Protective Helmet pipes Type A (low voltage) Type B (high voltage) falling objects Type C exposed electrical wiring or components Hair net or soft cap machine parts Other: other: HANDS/ARMS Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: PPE required to manage hazard: Comments: hazardous liquids/chemicals Gloves scrapes, bruise, or cut Chemical resistance Liquid/leak resistance Temperature resistance Cut resistance injuries from tools Gauntlet or long necked Work Gloves extreme heat/cold Chemical Protective sleeves blood (OPIM) Long sleeves other: Other: Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No FEET/LEGS Work-related exposure to: PPE required to manage hazard: Comments: hazardous liquids/chemicals closed shoes (e.g. no opened toes or sandals) heavy falling/rolling objects long pants heavy equipment Safety shoes or boots exposed electrical wiring or components Toe protection Metatarsal protection Electrical protection Heat/cold protection slippery surfaces Anti-slip soles Chemical resistance explosive atmospheres Leggings or chaps tools Foot-Leg guards other: Other: BODY/SKIN Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: PPE required to manage hazard: Comments: hazardous liquids/chemicals Lab Coat Raingear sharp or rough edges Coveralls, Body suit Apron extreme heat/cold Welding leathers Abrasion/cut
Employee Name/Title: Assessment Conducted by: Department: Date of Assessment: Job/Task(s): Effective Start Date: EYES/FACE Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: airborne dust flying particles hazardous liquids/chemicals intense light blood splashes other: PPE required to manage hazard: Safety glasses Safety goggles Face Shield Shading/Filter (# ) Welding shield Other: Comments: HEAD Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: beams pipes falling objects exposed electrical wiring or components machine parts other: PPE required to manage hazard: Protective Helmet Type A (low voltage) Type B (high voltage) Type C Hair net or soft cap Other: Comments: HANDS/ARMS Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: hazardous liquids/chemicals scrapes, bruise, or cut injuries from tools extreme heat/cold blood (OPIM) other: PPE required to manage hazard: Gloves Chemical resistance Liquid/leak resistance Temperature resistance Cut resistance Gauntlet or long necked Work Gloves Chemical Protective sleeves Long sleeves Other: Comments: FEET/LEGS Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: hazardous liquids/chemicals heavy falling/rolling objects heavy equipment exposed electrical wiring or components slippery surfaces explosive atmospheres tools other: PPE required to manage hazard: closed shoes (e.g. no opened toes or sandals) long pants Safety shoes or boots Toe protection Metatarsal protection Electrical protection Heat/cold protection Anti-slip soles Chemical resistance Leggings or chaps Foot-Leg guards Other: Comments: BODY/SKIN Negligible Hazard Can hazard be eliminated without the use of PPE? Yes No Work-related exposure to: hazardous liquids/chemicals sharp or rough edges extreme heat/cold PPE required to manage hazard: Lab Coat Raingear Coveralls, Body suit Apron Welding leathers Abrasion/cut Comments:
PPE_Hazard_Assessment_Form_12.28.17.docx