Operations PPE Hazard Assessment

This form may be used to certify the hazard assessment or surveyof the workplace to determine where physical or health hazards are present or likely to be present which

necessitate the use of personal protective equipment. Any additional or unique hazards should be added to this list of common sources and hazards. Keep the completed form as the permanent department record.

PERFORMED BY (Name & Title): / DEPARTMENT:
LOCATION (Building & Room):
NONE – Hazards requiring personal protective equipment are not present or likely to be present.
SOURCE /

ASSESSMENT OF HAZARD

/ PPE REQUIRED / COMPANION INFORMATION
AND TRAINING GUIDE
Use or handling of; /

Eye or face injury

/ Safety glasses With side shields / See Eye and Face Protection
Chemicals / Impact from flying particles / Safety goggles Chemical splash goggles
Biological agents, / Chemical splash in eyes / Face shield
human blood, OPIM / Facial skin chemical contact / Face mask for blood/OPIM only
Radioactive materials / Nose/mouth contact with blood/OPIM / Other ……………………………………………..
Body/skin/hand contact / Lab coat / Gown Latex gloves / See Protective Clothing
Biological agents / Apron Double latex gloves
Sharps / Scrubs Rubber gloves
Radioactive materials / Tyveks Chemical resistant gloves
Chemicals Hot or cold objects / Other………………
Operations generating / Respiratory: inhalation exposure /

Respirator

/ Respirator program is
airborne fiber, dust, fume, / above exposure standards / Filter or Cartridge El SCBA or air line / separate.
mist, or vapor / Other ………………………………………………
High noise levels from / Hearing: noise exposure above IOSH / Muff  Plugs / Hearing program is
equipment or operation / standards / Other...... ……………... / separate.

Non ionizing radiation sources

/ Radiation burns to: / Shaded safety glasses With side shields / See Eye and Face, Head,
Lasers Welding / Eyes, / Shaded safety goggles Welding helmet / and Protective Clothing
Infrared Ultraviolet / Body / Protective clothing (welding leathers, etc.)
Skin / Barriers, shields
Other …………………………………………….
General safety: physical / Foot Injury. equipment or object that / Safety shoes / See Foot Protection
hazards from equipment,
process, or material / can fall or roll onto feet / Other……………………………………………….
Impact or penetration to eye, face, / Safety glasses With side shields / See Eye and Face, Foot,
head, body, or soles of foot / Safety goggles Face shield / Head, and Protective
Electrical contact / Safety shoes Hard hats / Clothing.
Cut resistant gloves Coveralls
Other………………………………………………
Other: extreme heat or cold / Thermal gloves Face shields / See Eye and Face, Hand,
Thermal clothing Safety glasses / Foot, and Protective
Barriers /shields Other / Clothing.
Other

8/2006; reviewed 6/11/09