Hazard Assessment Form

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State of Hawaii
HAZARD ASSESSMENT CERTIFICATION *
Department: __________________________________________
Job Title of Employee: ______________________________________
Division/Branch: ______________________________________
Position Number: __________________________________________
Baseyard: ____________________________________________
Evaluated By (Print Name:): _________________________________
Work Unit: ___________________________________________
Position: ____________________________ Phone: _____________
Position Location (island, city): _________________________
*
Use special safety shoes form for foot protection. Not applicable for respiratory protection.
Describe Each Task or Activity
Hazard Associated with Task or Activity
Level, Size, Degree or Impact of Hazard Exposure
Hazard Assessment: Part of Body and Type of Protection Required:
Head
Body
Hard Hat (metal)
Spectacles
Apron
Face
Hands
Hard Hat (non-metal)
Ear Muffs
Body Suit
Eyes
Skin
Face Shield
Ear Plugs
Other: ____________
Ears
Other: ___________________
Goggles
Gloves
Other: ____________
Additional Requirements or sub category on the type of equipment (i.e. leather apron-welding): ____________________________________
_________________________________________________________________________________________________________________
Person certifying assessment:
____________________________
__________________________________
____________________
Print Name (if different from above)
Signature
Date

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