Can tasks in this work area Examples of Hazards PPE REQUIRED affect the following? (check all that apply) Falling objects Hardhat Head Working underneath scaffolding or other activity Other _______ Noise at or above 85 Ear plugs decibels Ear muffs Hearing Other _______ Both plugs and muffs at same time (ie. Noise is above 100 decibels) Chemical splash Long-sleeve shirt Torso Chemical dust Long pants Laceration Kevlar chaps Heat Cotton coverall Cold Fire resistant coverall Abrasion Tyvek coverall Other ________ Chemical resistant coverall Other _____________ Fall from height Full body harness Fall Protection Work in bucket truck Lanyard Roofing Anchor point Other __________ Certification: This certifies that the workplace has been evaluated for hazards to determine if personal protective equipment is required. Name of Workplace: Name of person certifying evaluation: Signature: Date:
Can tasks in this work area affect the following? Examples of Hazards PPE REQUIRED (check all that apply) Head Falling objects Working underneath scaffolding or other activity Other _______ Hardhat Hearing Noise at or above 85 decibels Other _______ Ear plugs Ear muffs Both plugs and muffs at same time (ie. Noise is above 100 decibels) Torso Chemical splash Chemical dust Laceration Heat Cold Abrasion Other ________ Long-sleeve shirt Long pants Kevlar chaps Cotton coverall Fire resistant coverall Tyvek coverall Chemical resistant coverall Other _____________ Fall Protection Fall from height Work in bucket truck Roofing Other __________ Full body harness Lanyard Anchor point Certification: This certifies that the workplace has been evaluated for hazards to determine if personal protective equipment is required. Name of Workplace: Name of person certifying evaluation: Signature: Date:
ppe-worksheet-2016.docx