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 ______________________________

 

EYES & FACE
Hazard	Yes	No	Eliminated, Guarded?	PPE Required
Flying particles
Molten metals
Liquid chemicals
Acids
Caustic liquids
Chemical gases or vapors
Light radiation
Other
Head
Hazard	Yes	No	Eliminated, Guarded?	PPE Required
Flying objects
Falling objects
Work done overhead
Elevated conveyors
Hitting against fixed object
Forklift hazards
Exposed electrical conductors
Other
Feet
Hazard	Yes	No	Eliminated, Guarded?	PPE Required
Flying objects
Rolling objects
Objects piercing sole
Electrical hazards
Wet, slippery or hot surfaces
Chemical exposure
Environmental
Other
Hands
Hazard	Yes	No	Eliminated, Guarded?	PPE Required
Skin absorption
Cuts or lacerations
Abrasions
Punctures
Chemical burns
Thermal burns
Temperature extremes
Other
Respiratory
Hazard	Yes	No	Eliminated, Guarded?	PPE Required
Dusts
Fogs
Fumes
Mists
Smokes
Sprays
Vapors
Other
Torso
Hazard	Yes	No	Eliminated, Guarded?	PPE Required
Hot metals
Cuts
Acids
Radiation
Other
Comments:

 

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 _____________________