Personal Protective Equipment (Short Version) Page 2
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3______________________________________________
Company Name
Personal Protective Equipment (PPE) Hazard Assessment
Location/ Jobs
Potential Hazards
Body Parts
Required PPE
Indicate Department, Job Title,
1 Sharp/ Abrasive Objects
18 Head
A Hard Hat/ Bump Cap
Equipment, Location or other
2 Flying Particles
19 Face
B Safety Glasses
identification of the task for
3 Falling Objects
20 Eye(s)
C Chemical Splash Goggles
which PPE is required:
4 Acidic/ Caustic Chemicals
21 Ear(s)
D Face Shield
5 Toxic Chemicals
22 Respiratory System
E Welding Helmet
6 Chemical Absorption
23 Trunk
F Ear Plugs
7 Temperature Extremes
24 Arm(s)
G Ear Muffs
8 Sparks/ Hot Particles
25 Hand(s)
H Personal Fall Protection (list)
9 Light Radiation
26 Finger(s)
I Gloves (list type)
10 Chemical Gases/ Vapors
27 Leg(s)
J Shoes/ Boots (list type)
11 Wet/ Slippery Surfaces
28 Foot/ Feet
K Respirator (list type)
12 Electrical Hazards
29 Toe(s)
L High Vis Vest/Clothing
13 Biohazards
30 Other (describe)
M Gauntlets (list type)
14 Noise
N Apron (list type)
15 Vehicular Traffic
O Coat/ Coverall
16 Fall from Heights
P Other (list type)
17 Other (describe)
*Potential Hazards
*Body Part(s)
*PPE Required
Example: Disinfection
Caustic chemicals
Hands
Heavy duty latex glove
*Insert description or corresponding #.
CERTIFICATION
This hazard assessment has been performed to determine the type of PPE required for each affected employee.
The assessment included a walk-through survey, specific job analysis, review of accident statistics, review of safety
equipment selection guidelines, and selection of appropriate required PPE.
Assessment Certified by (Supervisor) ____________________
Date _____________________
Company Name
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