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PPE Hazard Assessment Certification Form

This document is a PPE Hazard Assessment Certification Form for a workplace. It assesses potential hazards to various parts of the body for different jobs and tasks. For each part of the body, it identifies common work activities that pose risks, the nature of those risks, and whether the risks can be eliminated without PPE. If not, it specifies the type of PPE required to reduce or prevent the hazards. The goal is to properly certify the need for personal protective equipment in different work areas and functions to promote workplace safety.

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Haleem Ur Rashid Bangash
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1K views4 pages

PPE Hazard Assessment Certification Form

This document is a PPE Hazard Assessment Certification Form for a workplace. It assesses potential hazards to various parts of the body for different jobs and tasks. For each part of the body, it identifies common work activities that pose risks, the nature of those risks, and whether the risks can be eliminated without PPE. If not, it specifies the type of PPE required to reduce or prevent the hazards. The goal is to properly certify the need for personal protective equipment in different work areas and functions to promote workplace safety.

Uploaded by

Haleem Ur Rashid Bangash
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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PPE Hazard Assessment Certification Form

Name of work place: __________________________________


Work place address: __________________________________
_______________________________
Work area(s): _________________________________________
_______________________________________

Assessment conducted by: _________________________


Date of assessment:
Job/Task(s):

(Use a separate sheet for each job/task or work area)

EYES
Work activities, such as:
abrasive blasting
chopping
cutting
drilling
welding
soldering
torch brazing
working outdoors
computer work
punch press operations
other:

FACE
Work activities, such as:
cleaning
cooking
siphoning
painting
dip tank operations
pouring
other:
HEAD
Work activities, such as:
building maintenance
confined space operations
construction

sanding
sawing
grinding
hammering
chipping

foundry work
welding
mixing
pouring molten
metal
working outdoors

Work-related exposure to:


airborne dust
dirt
UV
flying particles/objects
blood splashes
hazardous liquid chemicals mists
chemical splashes
molten metal splashes
glare/high intensity lights
laser operations
intense light
hot sparks
other:

Can hazard be eliminated without the use of PPE?


Yes
No

Work-related exposure to:


hazardous liquid chemicals
extreme heat
extreme cold
potential irritants:
other:

Can hazard be eliminated without the use of PPE?


Yes
No

Work-related exposure to:


beams
pipes
exposed electrical wiring or

Can hazard be eliminated without the use of PPE?


Yes
No

If no, use:
Safety glasses
Safety goggles
Dust-tight goggles
Impact goggles
Welding helmet/shield
Chemical goggles
Chemical splash goggles
Laser goggles
Shading/Filter (#
)
Welding shield
Other:

If no, use:
Face shield
Shading/Filter (#
Welding shield
Other:

If no, use:
Protective Helmet

With:
Side shields
Face shield
Shaded
Prescription

electrical wiring
walking/working under catwalks
walking/working on catwalks
walking/working under conveyor belts
working with/around conveyor belts
walking/working under crane loads
utility work
other:
HANDS/ARMS
Work activities, such as:
baking
cooking
grinding
welding
working with glass
using computers
using knives
dental and health
care services
garbage disposal
computer work
other:

material handling
sanding
sawing
hammering
using power tools
working outdoors

FEET/LEGS
Work activities, such as:
building maintenance
construction
demolition
food processing
foundry work
working outdoors
logging
plumbing
trenching
use of highly flammable materials
welding
other:

components
falling objects
fixed object
machine parts
other:

Type A (low voltage)


Type B (high voltage)
Type C
Bump cap (not ANSI-approved)
Hair net or soft cap
Other:

Work-related exposure to:


blood
irritating chemicals
tools or materials that could scrape,
bruise, or cut
extreme heat
extreme cold
animal bites
electric shock
vibration
musculoskeletal disorders
sharps injury
other:

Can hazard be eliminated without the use of PPE?


Yes
No

Work-related exposure to:


explosive atmospheres
explosives
exposed electrical wiring or
components
heavy equipment
slippery surfaces
impact from objects
pinch points
crushing
slippery/wet surface
sharps injury
blood
chemical splash
chemical penetration
extreme heat/cold

Can hazard be eliminated without the use of PPE?


Yes
No

If no, use:
Gloves
Chemical resistance
Liquid/leak resistance
Temperature resistance
Abrasion/cut resistance
Slip resistance
Latex or nitrile
Anti-vibration
Protective sleeves
Ergonomic equipment_____________________
Other:

If no, use:
Safety shoes or boots
Toe protection
Electrical protection
Puncture resistance
Anti-slip soles
Leggings or chaps
Foot-Leg guards
Other:

Metatarsal protection
Heat/cold protection
Chemical resistance

fall
other:
BODY/SKIN
Work activities such as:
baking or frying
battery charging
dip tank operations
fiberglass installation
sawing
other:

BODY/WHOLE
Work activities such as:
building maintenance
construction
logging
computer work
working outdoors
utility work
other:

Work-related exposure to:


chemical splashes
extreme heat
extreme cold
sharp or rough edges
irritating chemicals
other:

Can hazard be eliminated without the use of PPE?


Yes
No

Work-related exposure to:


working from heights of 10 feet or
more
impact from flying objects
impact from moving vehicles
sharps injury
blood
electrical/static discharge
hot metal
musculoskeletal disorders
sparks
chemicals
extreme heat/cold
elevated walking/working surface
working near water
injury from slip/trip/fall
other:

Can hazard be eliminated without the use of PPE?


Yes
No

If no, use:
Vest, Jacket
Coveralls, Body suit
Raingear
Apron
Welding leathers
Abrasion/cut resistance
Other:

With:
Long sleeves

If no, use:
With:
Fall Arrest/Restraint
Hood
Traffic vest
Full sleeves
Static coats/overalls
Flame resistant jacket/pants
Insulated jacket
Cut resistant sleeves/wristlets
hoists/lifts
ergonomic equipment: _____________________
Other:

LUNGS/RESPIRATORY
Work activities such as:
cleaning
pouring
mixing
sawing
painting
fiberglass installation
compressed air or gas operations
confined space work
floor installation
ceiling repair
working outdoors
other:

EARS/HEARING
Work activities such as:
generator
ventilation fans
motors
sanding
pneumatic equipment
punch or brake presses
use of conveyors
other:

grinding
machining
routers
sawing
sparks

Work-related exposure to:


dust or particulate
toxic gas/vapor
chemical irritants (acids)
welding fume
asbestos
pesticides
organic vapors
oxygen deficient environment
paint spray
extreme heat/cold
other:

Can hazard be eliminated without the use of PPE?


Yes
No

Work-related exposure to:


loud noises
loud work environment
noisy machines/tools
punch or brake presses
other:

Can hazard be eliminated without the use of PPE?


Yes
No

If no, use:
Dust mask
Disposable particulate
respirator
Replaceable filter particulate
w/cartridge
PAPR (Air recycle)
PPSA (Air supply)

If no, use:
ear muffs
ear plugs
leather welding hood

With/Type:
face shield
acid/gas crtdg
organic crtdg
pesticide crtdg
spray paint
crtdg
half faced
full faced
hooded

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