Ithaca College - Personal Protective Equipment Assessment Form

ITHACA COLLEGE – PERSONAL PROTECTIVE EQUIPMENT ASSESSMENT FORM

This form is intended to guide supervisors and managers in assessing their work place(s) for hazards that necessitate the use of personal protective equipment (PPE).

Once complete, send a copy of this form to EH&S for recommendations and assistance with PPE selection.

Department/Office: _________________________________________ Name & Job Title of Person Performing PPE Assessment: ____________________________________

Date of Assessment: ________________________________________

*Indicate in the Corresponding Box All Applicable Hazards for Each Job and/or Task Under Your Supervision*

Eye/Face

Head

Torso/Limbs

(2)

Hand

Respiratory

(flying particles or

(falling objects;

(splashing

chips; molten

(skin absorption of

flying objects;

(harmful dusts;

chemicals; flying

metal; liquid

harmful substances or

impact with

fogs; fumes; mists;

debris; abrasion,

Foot

chemicals; acidic

infectious materials;

heavy

gases; smokes;

cuts or

(heavy falling objects;

(1)

Hearing

or caustic liquids;

severe cuts or

equipment,

sprays; or vapors

lacerations;

Job Title & Task Description

heavy rolling objects;

chemical gases

(Noise above

lacerations; severe

machines, or

that can not be

temperature

compression/crushing;

vapors, or mists;

90 decibels)

abrasions; punctures;

other objects;

reduced to safe

extremes;

puncture hazard;

intense

chemical burns; thermal

electric shock

levels by ventilation

electric arc; low

electrical hazards

light/radiation;

burns; harmful

systems or other

visibility to

splashing of

temperatures; electric

engineering

vehicle traffic;

infectious

arc

controls)

other hazards to

materials

health)

Notes:

1 – Refer to the latest noise monitoring survey conducted by EH&S.

2 – An assessment of respiratory hazards has been conducted by EH&S. Use of a respirator requires prior medical clearance, specific training, and participation in the Ithaca College Respiratory Protection Program. Contact

EH&S if there is a question about whether a particular task requires the mandatory use of a respirator. Employees may not wear respirators (except dust masks) without being included in the Respiratory Protection Program.

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