Personal Protective Equipment Hazard Assessment Form Page 2
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1
2PART II
CERTIFICATION OF HAZARD ASSESSMENT
INSTRUCTIONS: Transfer information from Part I to the appropriate sections below. (1) Familiarize yourself with the potential hazards
and the types of PPE that are available to protect against the hazards. (2) Consider the magnitude and other characteristics of the hazard(s)
and environment; such as impact velocities, masses, projectile shape, strength of chemical compositions, concentrations of dusts, mists,
gasses, fumes, radiant energy intensities, etc. (3) Select PPE that ensures a greater level of protection than the minimum required to protect
workers from the hazards. Specify PPE by evaluative criteria, and/or manufacturer, model, size, and other applicable features. (4) Fit the
PPE to the worker, train the worker in PPE use and care. Ensure workers are aware of all limitations, warning labels, and other
characteristics of the PPE. Instruct employees on who to contact if they have problems or questions pertaining to their PPE.
BASED ON THE HAZARD ASSESSMENT FOR __________________________________THE FOLLOWING PPE IS REQUIRED:
(Job Classification)
A
. HEAD HAZARDS:
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
B.
EYE HAZARDS
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
C
. HAND HAZARDS
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
D
.
FOOT HAZARDS
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
Certification: I certify that this Hazard Evaluation was conducted as described above, in a good-faith
effort to comply with the applicable Hazard Assessment portions of 29 CFR 1910.132.
Signed____________________________________________Date_______________________________
(Adapted from an internet document posted by N. C. State University)
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