Tool: PPE Hazard Assessment Form
PPE HAZARD ASSESSMENT FORM
Use and modify this sample form to help you determine what hazards workers are exposed to and what PPE must be worn to protect them.
- If you check YES, determine if the hazard can be eliminated.
- If NO, can the method or equipment be changed to eliminate the hazard?
- If so, consider doing it.
- If the hazard can’t be eliminated, would adding a guard protect employees from the hazard, e.g., machine guards?
- If this is the case, indicate a guard is being installed.
- In the last column, list the type of PPE the worker will be required to use.
PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT
Facility____________________ Dept.________________ Date_________
Supervisor _________________ Job ______________________________
EYES & FACE | ||||
Hazard | Yes | No | Eliminated, Guarded? | PPE Required |
Flying particles | ||||
Molten metals | ||||
Liquid chemicals | ||||
Acids | ||||
Caustic liquids | ||||
Chemical gases or vapors | ||||
Light radiation | ||||
Other | ||||
Head | ||||
Hazard | Yes | No | Eliminated, Guarded? | PPE Required |
Flying objects | ||||
Falling objects | ||||
Work done overhead | ||||
Elevated conveyors | ||||
Hitting against fixed object | ||||
Forklift hazards | ||||
Exposed electrical conductors | ||||
Other | ||||
Feet | ||||
Hazard | Yes | No | Eliminated, Guarded? | PPE Required |
Flying objects | ||||
Rolling objects | ||||
Objects piercing sole | ||||
Electrical hazards | ||||
Wet, slippery or hot surfaces | ||||
Chemical exposure | ||||
Environmental | ||||
Other | ||||
Hands | ||||
Hazard | Yes | No | Eliminated, Guarded? | PPE Required |
Skin absorption | ||||
Cuts or lacerations | ||||
Abrasions | ||||
Punctures | ||||
Chemical burns | ||||
Thermal burns | ||||
Temperature extremes | ||||
Other | ||||
Respiratory | ||||
Hazard | Yes | No | Eliminated, Guarded? | PPE Required |
Dusts | ||||
Fogs | ||||
Fumes | ||||
Mists | ||||
Smokes | ||||
Sprays | ||||
Vapors | ||||
Other | ||||
Torso | ||||
Hazard | Yes | No | Eliminated, Guarded? | PPE Required |
Hot metals | ||||
Cuts | ||||
Acids | ||||
Radiation | ||||
Other | ||||
Comments:
|
Certification
This hazard assessment has been performed to determine the required type of PPE for each affected worker.
The assessment includes:
- Walk-through survey
- Specific job analysis
- Review of accident statistics
- Review of safety equipment selection guideline materials
- Selection of appropriate required PPE
Assessment Certified by (Supervisor) ______________________ Date _____________________