New Employee Ppe Hazardous Assessment Form Page 2
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4PPE Hazard Assessment Certification Form
*Name of work place: __________________________________
*Assessment conducted by: _________________________
*Work place address: __________________________________
*Date of assessment: _______________________________
Work area(s): _________________________________________
Job/Task(s): _______________________________________
*Required for certifying the hazard assessment.
Use a separate sheet for each job/task or work area
EYES
Work activities, such as:
Work-related exposure to:
Can hazard be eliminated without the use of PPE?
abrasive blasting
sanding
airborne dust
Yes
No
chopping
sawing
flying particles
If no, use:
cutting
grinding
blood splashes
Safety glasses
Side shields
drilling
hammering
hazardous liquid chemicals
Safety goggles
Dust-tight
welding
intense light
Shading/Filter (#
)
goggles
punch press operations
other:
Welding shield
other:
Other:
FACE
Work activities, such as:
Work-related exposure to:
Can hazard be eliminated without the use of PPE?
cleaning
foundry work
hazardous liquid chemicals
Yes
No
cooking
welding
extreme heat/cold
If no, use:
siphoning
mixing
potential irritants:
Face shield
painting
pouring molten
other:
Shading/Filter (#
)
dip tank operations
metal
Welding shield
other
Other:
HEAD
Work activities, such as:
Work-related exposure to:
Can hazard be eliminated without the use of PPE?
building maintenance
beams
Yes
No
confined space operations
pipes
If no, use:
construction
exposed electrical wiring or
Protective Helmet
electrical wiring
components
Type A (low voltage)
walking/working under catwalks
falling objects
Type B (high voltage)
walking/working under conveyor belts
machine parts
Type C
walking/working under crane loads
other:
Bump cap (not ANSI-approved)
utility work
Hair net or soft cap
other:
Other:
OREGON
WASHINGTON
2637 SE 12
Avenue
6018 234
Street SE, Suite A
th
th
Portland, OR 97202
Woodinville, WA 98072
(503) 234-4321
(425) 487-6161
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