PPE HAZARD ASSESSMENT FORM

Use and modify this sample form to help you determine what hazards workers are exposed to and what PPE must be worn to protect them.

• If you check YES, determine if the hazard can be eliminated.
• If NO, can the method or equipment be changed to eliminate the hazard?
  • If so, consider doing it.
• If the hazard can’t be eliminated, would adding a guard protect employees from the hazard, e.g., machine guards?
  • If this is the case, indicate a guard is being installed.
• In the last column, list the type of PPE the worker will be required to use.

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT

Facility____________________  Dept.________________ Date_________

Supervisor _________________   Job ______________________________

Certification

This hazard assessment has been performed to determine the required type of PPE for each affected worker.

The assessment includes:

• Walk-through survey
• Specific job analysis
• Review of accident statistics
• Review of safety equipment selection guideline materials
• Selection of appropriate required PPE

Assessment Certified by (Supervisor) ______________________ Date _____________________