State Of Hawaii Hazard Assessment Certification (Fillible)

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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): ___________________________
Duties: ___ Mostly outdoors; ___ Mostly indoors
Task, Activity, Hazard Source (1)
Assessment of Hazard (2)
Protection (3)
Hazard Assessment; Type of protection required for tasks shown above:
Base:  Impact/compression
Additional:  High cut - height:
6"____; 8" ____ ; Other: ______________
 Metatarsal
 Slip resistant
 Electrical
 Water resistant
 Sole Protection
 Heat resistant (soles)
 Water resistant boots
 Fire resistant (welding)
Impact and compression requirement:
30 _____, 50 _____, or 75 _____ .
Person certifying assessment: ______________________________
___________________________________
______________________
Print Name (if different from above)
Signature
Date

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