Whole body Work activities such as: Work-related exposure to: Can hazard be eliminated without the use of PPE? □ Building maintenance □ Working from heights of 10 feet or □ Construction more □ Yes □ No □ Logging □ Working near water □ Utility work □ Other: ____________________ If no, use: □ Other: __________________ □ Fall arrest/restraint Type: __________________ □ PFD Type: ___________________ □ Other: ___________________ Lungs/respiratory Work activities such as: Work-related exposure to: Can hazard be eliminated without the use of PPE? □ Cleaning □ Irritating dust or particulate □ Mixing □ Irritating or toxic gas or vapor □ Yes □ No □ Painting □ Other: __________________ □ Fiberglass installation □ Compressed air or gas operations □ Other: __________________ Ears/hearing Work activities such as: Work-related exposure to: Can hazard be eliminated without the use of PPE? □ Generator □ Loud noises □ Ventilation fans □ Loud work environment □ Yes □ No □ Motors □ Noisy machines/tools □ Sanding □ Punch or brake presses □ Pneumatic equipment □ Other: ___________________ □ Punch or brake presses □ Use of conveyors □ Grinding □ Machining □ Routers □ Sawing □ Others: ________________ Source: “,” State of Washington Department of Labor and Industries.
Whole body Work activities such as: □ Building maintenance □ Construction □ Logging □ Utility work □ Other: __________________ Work-related exposure to: □ Working from heights of 10 feet 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: □ Cleaning □ Mixing □ Painting □ Fiberglass installation □ Compressed air or gas operations □ Other: __________________ Work-related exposure to: □ Irritating dust or particulate □ Irritating or toxic gas or vapor □ Other: __________________ Can hazard be eliminated without the use of PPE? □ Yes □ No Ears/hearing Work activities such as: □ Generator □ Ventilation fans □ Motors □ Sanding □ Pneumatic equipment □ Punch or brake presses □ Use of conveyors □ Grinding □ Machining □ Routers □ Sawing □ Others: ________________ Work-related exposure to: □ Loud noises □ Loud work environment □ Noisy machines/tools □ Punch or brake presses □ Other: ___________________ Can hazard be eliminated without the use of PPE? □ Yes □ No Source: “,” State of Washington Department of Labor and Industries.
PPE_hazard_assesment_certification_form.docx