Certification Of Hazard Assessment Form For Ppe Use

Download a blank fillable Certification Of Hazard Assessment Form For Ppe Use in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Certification Of Hazard Assessment Form For Ppe Use with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

CERTIFICATION OF HAZARD ASSESSMENT FORM FOR PPE USE
To be reviewed annually
The OSHA Standard states: The employer shall assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of personal protective equipment (PPE).
1910.132(d)(1) The employer shall verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that the
evaluation has been performed; the date(s) of the hazard assessment; and, which identifies the document as a certification of hazard assessment. 1910.132(d)(2)
This form may be used to certify (document in writing) your hazard assessment. Keep it on permanent file in your department.
PERFORMED BY (Name & Title):
DEPARTMENT:
LOCATION (Building & Room):
________________________________________________________
DATE: ____________
NONE – Hazards requiring personal protective equipment are not present or likely to be present.
SOURCE
ASSESSMENT OF HAZARD
PPE REQUIRED
COMMENTS
Use or handling of;
Eye or face injury
Safety glasses
With side shields
Chemicals
Impact from flying particles
Safety goggles
Chemical splash goggles
Biological agents,
Chemical splash in eyes
Face shield
human blood, OPIM
Facial skin chemical contact
Face mask for blood/OPIM only
Radioactive materials
Nose/mouth contact with blood/OPIM
Other ……………………………………………..
Body/skin/hand contact
Lab coat / Gown
Latex gloves
Biological agents
Apron
Double latex gloves
Sharps
Scrubs
Rubber gloves
Radioactive materials
Tyveks
Chemical resistant gloves
Chemicals
Hot or cold objects
Other………………
Operations generating
Required: inhalation exposure
Respirator
Respirator program is
airborne fiber, dust, fume,
above exposure standards
Filter or Cartridge El SCBA or air line
separate.
mist, or vapor
Voluntary: inhalation exposure below
Other ………………………………………………
Contact EHS.
Standard
High noise levels from
Hearing: noise exposure above IOSH
Muff
Ear Plugs
Hearing program is
equipment or operation
standards
Other...............................................……………...
separate.
Non ionizing radiation sources
Radiation burns to:
Shaded safety glasses
With side shields
Lasers
Welding
Eyes,
Shaded safety goggles
Welding helmet
Infrared
Ultraviolet
Body
Protective clothing (welding leathers, etc.)
Skin
Barriers, shields
Other …………………………………………….
General safety: physical
Foot Injury. equipment or object that
Safety shoes
hazards from equipment,
can fall or roll onto feet
Other……………………………………………….
process, or material
Impact or penetration to eye, face,
Safety glasses
With side shields
head, body, or soles of foot
Safety goggles
Face shield
Electrical contact
Safety shoes
Hard hats
Cut resistant gloves
Coveralls
Other………………………………………………
Other: extreme heat or cold
Thermal gloves
Face shields
Thermal clothing
Safety glasses
Barriers /shields
Other
Other
Form updated: April 2016

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go