8/10/2019 PPE Hazard Assessment Certification Form

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PPE Hazard Assessment Certification Form

Name of work place: __________________________________ Assessment conducted by: _________________________

Work place address: __________________________________ Date of assessment:_______________________________

Work areas!: _________________________________________ "ob#$asks!:_______________________________________

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

E%E&

Work activities, such as:abrasive blasting sandingchopping sawingcutting grindingdrilling hammeringwelding chippingsolderingtorch braing

working outdoorscomputer workpunch press operationsother:

Work!related e"posure to:airborne dustdirtU#fl$ing particles/objectsblood splasheshaardous li%uid chemicals mistschemical splashes

molten metal splashesglare/high intensit$ lightslaser operationsintense lighthot sparksother:

&an haard be eliminated without the use of ''*es +o

f no, use: With:-afet$ glasses -ide shields-afet$ goggles .ace shieldust!tight goggles -hadedmpact goggles 'rescriptionWelding helmet/shield

&hemical goggles&hemical splash goggles0aser goggles-hading/.ilter (1 )Welding shield2ther:

FACE

Work activities, such as:cleaning foundr$ workcooking weldingsiphoning mi"ingpainting pouring moltendip tank operations metalpouring working outdoorsother:

Work!related e"posure to:haardous li%uid chemicalse"treme heate"treme coldpotential irritants:other:

&an haard be eliminated without the use of ''*es +o

f no, use:.ace shield-hading/.ilter (1 )Welding shield2ther:

HEAD

Work activities, such as:building maintenance

confined space operationsconstruction

Work!related e"posure to:beams

pipese"posed electrical wiring or

&an haard be eliminated without the use of ''*es +o

f no, use:'rotective 3elmet

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electrical wiringwalking/working under catwalkswalking/working on catwalkswalking/working under conve$or beltsworking with/around conve$or beltswalking/working under crane loadsutilit$ workother:

componentsfalling objectsfi"ed objectmachine partsother:

4$pe 5 (low voltage)4$pe 6 (high voltage)4$pe &6ump cap (not 5+-!approved)

3air net or soft cap2ther:

HANDA'(&

Work activities, such as:baking material handlingcooking sandinggrinding sawingwelding hammeringworking with glass using power toolsusing computers working outdoorsusing knives

dental and healthcare servicesgarbage disposalcomputer workother:

Work!related e"posure to:bloodirritating chemicalstools or materials that could scrape,bruise, or cut

e"treme heate"treme coldanimal bites

electric shockvibrationmusculoskeletal disorderssharps injur$other:

&an haard be eliminated without the use of ''*es +o

f no, use:7loves

&hemical resistance0i%uid/leak resistance4emperature resistance5brasion/cut resistance-lip resistance0ate" or nitrile5nti!vibration

'rotective sleevesrgonomic e%uipment_____________________2ther:

FEE$#)E*&

Work activities, such as:building maintenanceconstructiondemolitionfood processingfoundr$ workworking outdoorsloggingplumbingtrenchinguse of highl$ flammable materialsweldingother:

Work!related e"posure to:e"plosive atmospherese"plosivese"posed electrical wiring orcomponents

heav$ e%uipmentslipper$ surfacesimpact from objectspinch pointscrushingslipper$/wet surfacesharps injur$bloodchemical splashchemical penetratione"treme heat/cold

&an haard be eliminated without the use of ''*es +o

f no, use:-afet$ shoes or boots

4oe protection 8etatarsal protectionlectrical protection 3eat/cold protection'uncture resistance &hemical resistance5nti!slip soles

0eggings or chaps.oot!0eg guards2ther:

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fallother:

+,D%#&-.N

Work activities such as:baking or fr$ingbatter$ charging

dip tank operationsfiberglass installationsawingother:

Work!related e"posure to:chemical splashese"treme heat

e"treme coldsharp or rough edgesirritating chemicalsother:

&an haard be eliminated without the use of ''*es +o

f no, use: With:

#est, 9acket 0ong sleeves&overalls, 6od$ suitaingear5pronWelding leathers5brasion/cut resistance2ther:

+,D%#WH,)E

Work activities such as:building maintenanceconstructionloggingcomputer workworking outdoorsutilit$ workother:

Work!related e"posure to:working from heights of ;< feet ormore

impact from fl$ing objectsimpact from moving vehiclessharps injur$bloodelectrical/static dischargehot metalmusculoskeletal disorderssparkschemicalse"treme heat/coldelevated walking/working surfaceworking near waterinjur$ from slip/trip/fallother:

&an haard be eliminated without the use of ''*es +o

f no, use: With:.all 5rrest/estraint 3ood4raffic vest .ull sleeves-tatic coats/overalls.lame resistant jacket/pantsnsulated jacket&ut resistant sleeves/wristletshoists/liftsergonomic e%uipment: _____________________2ther:

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)/N*'E&P.'A$,'%

Work activities such as:cleaning pouringmi"ing sawingpaintingfiberglass installationcompressed air or gas operations

confined space workfloor installationceiling repairworking outdoorsother:

Work!related e"posure to:dust or particulateto"ic gas/vaporchemical irritants (acids)welding fumeasbestos

pesticidesorganic vaporso"$gen deficient environmentpaint spra$e"treme heat/coldother:

&an haard be eliminated without the use of ''*es +o

f no, use: With/4$pe:ust mask face shieldisposable particulate acid/gas crtdg

respirator organic crtdgeplaceable filter particulate pesticide crtdg w/cartridge spra$ paint

'5' (5ir rec$cle) crtdg''-5 (5ir suppl$) half faced

full faced hooded

EA'HEA'.N*

Work activities such as:generator grinding

ventilation fans machiningmotors routerssanding sawingpneumatic e%uipment sparkspunch or brake pressesuse of conve$orsother:

Work!related e"posure to:loud noises

loud work environmentnois$ machines/toolspunch or brake pressesother:

&an haard be eliminated without the use of ''*es +o

f no, use:ear muffsear plugsleather welding hood