Personal Protective Equipment

Personal Protective Equipment

The following equipment is required in this work area: _________________________________

Task

Eye

Ear Plugs

Gloves

Feet

Apron

Respirator

ANSI

Hard

Fall

Other

Protection

or

Hi-Vis

Hat

Protection

Ear Muffs

clothing

X Safety

X

X

X

X—Kevlar

For example: Chainsaw operations

glasses with

Chaps

faceshield

For example: Electroplating operations

X goggles

X nitrile

X

X

This certifies that the workplace has been evaluated for hazards in order to determine if personal protective equipment is required.

Signature of person conducting the assessment: _____________________________ Date: ____________

This summary is an optional format intended to help communicate PPE requirements to employees. Each employer may develop their own format. You may add PPE icons that apply to your worksite.

A certification statement is required. Based on workplace hazards, other programs, such as a Respirator Program, Hazard Communication, or Hearing Conservation Program, may also be required.