Ppe Hazard Assessment/training Certification Form

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PPE HAZARD ASSESSMENT/TRAINING CERTIFICATION FORM
November 2005, version 1.2
Work Area(s): ____________________________________________ Job/Task(s): _____________________________________________
(Use a separate sheet for each task)
Assessment Conducted By: _____________________________________________________________________ Date: ______________
Exposed
Hazard Type(s)
Personal Protective Equipment (PPE) Required
Body Part
Falling/Flying Objects
Can hazard(s) be adequately controlled with engineering and
Harmful Dusts
administrative controls?
Yes
No
If no, specify PPE:
o
o
Extreme Heat/Cold
(burns, frostbite)
1
Protection
2
Protection
o
Chemical
(irritation, burns, exposures)
Eye/Face
Safety Glasses
(w/ 1
Protection)
Optical (light) Radiation
Goggles
Face Shield
Biological
(exposures to mucus membranes)
Filter Lenses - shade: _______ (2-14)
Welding Helmet
Laser Goggles - OD: ________ (5-8)
Chemical
(irritation, burns, exposures)
Can hazard(s) be adequately controlled with engineering and
Scrapes/Cuts/Punctures
administrative controls?
Yes
No
If no, specify PPE:
Extreme Heat/Cold
(burns, frostbite)
Chemical/Liquid Resistant Gloves
Specify:
Electrical Shock/Burn
Hand/Arm
Temperature Resistant Gloves
Biological
(exposures to damaged skin)
Abrasion/Cut/Puncture Resistant Gloves
Radiological
Slip Resistant Gloves
Non-Conductive Gloves
Chemical
Can hazard(s) be adequately controlled with engineering and
Respiratory
Harmful Dusts
administrative controls?
Yes
No
If no, Contact RM&S @
Tract
Biological
621-1570 regarding Respiratory Protection Program.
Radiological
Excessive Noise
(consider if you must raise voice to
Can hazard(s) be adequately controlled with engineering and
communicate @ 3 feet)
administrative controls?
Yes
No
If no, Contact RM&S @
Hearing
Chemical
(affecting auditory nerve)
621-1570 regarding Hearing Conservation Program and specify PPE:
Ear Plugs type _____NRR
Ear Muffs type _____NRR
Falling Objects
Can hazard(s) be adequately controlled with engineering and
Electrical Shock/Burn
administrative controls?
Yes
No
If no, specify PPE:
Head
Bumping Against Fixed Objects
Hard Hat - type _____ (A – low voltage, B – high voltage, or C)
Bump Hat (not for falling/flying objects – not ANSI approved)
Falling/Rolling Objects
Can hazard(s) be adequately controlled with engineering and
Punctures
administrative controls?
Yes
No
If no, specify PPE:
Chemical
Safety Shoes
Toe/Metatarsal Guards
Specify:
Foot/Leg
Extreme Heat/Cold
(burns, frostbite)
Leggings
Combo. Foot/Shin Guards
Electrical Shock/Burn
(contact w/electrical hazards)
Shoe Covers
Conductive Shoes
Other
Non-Conductive Safety Shoes
Chemical
Can hazard(s) be adequately controlled with engineering and
Harmful Dusts
administrative controls?
Yes
No
If no, specify PPE:
Extreme Heat/Cold
(burns, frostbite, heat/cold stress)
Apron
Lab Coat
Specify:
Electrical Shock/Burn
Coverall
Gown
Body
Radiological
Vest
Full-Body Suit
Biological
(exposures to damaged skin)
Jacket
Personal Fall Arrest System
Falls
(consider when working 4 feet above lower
Other
surface)

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