PPE Hazard Assessment Certification Form

Laboratory location: ______________________ Assessment conducted by: __________________

Investigator: ____________________________ Date of assessment: __________________
Work area(s): _________________________________ Job/Task(s): ________________________
(Use a separate sheet for each job/task or work area)

EYES
Work activities, such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
abrasive blasting sanding airborne dust Yes No
chopping sawing dirt
If no, use: With:
cutting grinding UV
Safety glasses Side shields
drilling hammering flying particles/objects
Safety goggles Face shield
chipping blood splashes
Dust-tight goggles Shaded
computer work hazardous liquid chemicals mists
Impact goggles Prescription
other: chemical splashes
Chemical goggles
glare/high intensity lights
Chemical splash goggles
laser operations
Laser goggles
intense light
Shading/Filter (# )
hot sparks
Welding shield
other:
Other:

FACE
Work activities, such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
cleaning hazardous liquid chemicals Yes No
siphoning extreme heat
If no, use:
painting extreme cold
Face shield
mixing potential irritants:
Shading/Filter (# )
pouring other:
Welding shield
other:
Other:

HANDS/ARMS
Work activities, such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
material handling sanding blood Yes No
grinding sawing irritating chemicals
If no, use:
hammering tools or materials that could scrape,
Gloves
working with glass using power tools bruise, or cut
Chemical resistance
using computers extreme heat
Liquid/leak resistance
using knives extreme cold
Temperature resistance
 computer work animal bites Abrasion/cut resistance
other: electric shock Slip resistance
vibration Latex or nitrile
musculoskeletal disorders Anti-vibration
sharps injury Protective sleeves
other: Ergonomic equipment_____________________
Other:

FEET/LEGS
Work activities, such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
use of corrosive or flammable materials explosive atmospheres Yes No
other: explosives
If no, use:
crushing
Safety shoes or boots
sharps injury
Toe protection Metatarsal protection
blood
Electrical protection Heat/cold protection
chemical splash
Puncture resistance Chemical resistance
chemical penetration
Anti-slip soles
extreme heat/cold
Leggings or chaps
other:
Foot-Leg guards
Other:

BODY/SKIN & BODY/ WHOLE

Work activities such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
use of corrosive or flammable chemicals chemical splashes Yes No
other: extreme heat
If no, use: With:
extreme cold
Vest, Jacket Long or full
sharp or rough edges
Flame resistant jacket/pants sleeves
irritating chemicals
Hood
other:
Coveralls, Body suit
Raingear
Apron
Abrasion/cut resistance
Other:
LUNGS/RESPIRATORY
Work activities such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
cleaning pouring dust or particulate Yes No
mixing sawing toxic gas/vapor
compressed air or gas operations chemical irritants (acids) If no, use: With/Type:
confined space work pesticides Dust mask face shield
other: organic vapors Disposable particulate acid/gas crtdg
oxygen deficient environment respirator organic crtdg
extreme heat/cold Replaceable filter particulate pesticide crtdg
other: w/cartridge spray paint
PAPR (Air recycle) crtdg
PPSA (Air supply) half faced
full faced
hooded

EARS/HEARING
Work activities such as: Work-related exposure to: Can hazard be eliminated without the use of PPE?
generator grinding loud noises Yes No
ventilation fans machining loud work environment
motors routers noisy machines/tools If no, use:
sanding sawing punch or brake presses ear muffs
pneumatic equipment sparks other: ear plugs
other: