Sample Personal Protective Equipment (Ppe) Hazard Assessment Survey and Analysis Form

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Personal Protective Equipment (PPE)
I. PURPOSE
This program provides for the proper selection and use of Personal Protective Equipment (PPE) at the
[insert facility name].
II. SCOPE
A PPE assessment must be conducted in all non-office environment work areas to identify physical and
chemical hazards warranting PPE use when engineering, work practice and administrative controls are
not feasible. PPE is barrier clothing or gear worn to protect the eyes, face, head, hands, feet, and body
from identified hazards.
III. RESPONSIBILITIES/ROLES
[insert job title]
Reviews the requirements of the PPE standard, determines applicability to the site and assists in
implementing the program requirements for this facility.
All Employees - Follow applicable program requirements and communicate with their supervisor when
there are safety issues not specifically addressed by the hazard assessment.
IV. PROGRAM ELEMENTS
1. PPE Hazard Assessments
[insert job title(s)] will perform, document\certify that a PPE hazard assessment to identify hazards for
each work task(s) has been conducted. [insert job title(s)] will also review this PPE hazard assessment
when changes occur to the work task or work environment. A PPE hazard assessment will also be
conducted for new equipment, processes, and tasks where new job hazards are introduced.
[insert job title(s)] will select appropriate PPE based upon any recognized Physical or Chemical Hazard.
[a sample PPE Hazard Assessment is attached]
2. General PPE Requirements
If PPE is required when performing tasks in certain areas, the facility shall develop signage to indicate the
PPE requirements. These signs should be posted at entrances to the applicable areas to remind
employees, contractors, and visitors of the requirement to wear PPE while in this specific area.
[e.g. Signage that indicates the use of safety glasses in the wood shop]
3. Specific PPE Requirements
PPE needs are determined by the PPE hazard assessment, which considers hazards, current controls in
place and additional protective requirements.
The facility will consider the following when evaluating PPE needs:
Eye and face protection when there is a potential to encounter hazards such as flying debris, chemical
splashes and harmful light. Face shields used for splash protection must be used in conjunction with
either safety glasses or goggles.
PPE 12/14
Personal Protective Equipment (PPE)
I. PURPOSE
This program provides for the proper selection and use of Personal Protective Equipment (PPE) at the
[insert facility name].
II. SCOPE
A PPE assessment must be conducted in all non-office environment work areas to identify physical and
chemical hazards warranting PPE use when engineering, work practice and administrative controls are
not feasible. PPE is barrier clothing or gear worn to protect the eyes, face, head, hands, feet, and body
from identified hazards.
III. RESPONSIBILITIES/ROLES
[insert job title]
Reviews the requirements of the PPE standard, determines applicability to the site and assists in
implementing the program requirements for this facility.
All Employees - Follow applicable program requirements and communicate with their supervisor when
there are safety issues not specifically addressed by the hazard assessment.
IV. PROGRAM ELEMENTS
1. PPE Hazard Assessments
[insert job title(s)] will perform, document\certify that a PPE hazard assessment to identify hazards for
each work task(s) has been conducted. [insert job title(s)] will also review this PPE hazard assessment
when changes occur to the work task or work environment. A PPE hazard assessment will also be
conducted for new equipment, processes, and tasks where new job hazards are introduced.
[insert job title(s)] will select appropriate PPE based upon any recognized Physical or Chemical Hazard.
[a sample PPE Hazard Assessment is attached]
2. General PPE Requirements
If PPE is required when performing tasks in certain areas, the facility shall develop signage to indicate the
PPE requirements. These signs should be posted at entrances to the applicable areas to remind
employees, contractors, and visitors of the requirement to wear PPE while in this specific area.
[e.g. Signage that indicates the use of safety glasses in the wood shop]
3. Specific PPE Requirements
PPE needs are determined by the PPE hazard assessment, which considers hazards, current controls in
place and additional protective requirements.
The facility will consider the following when evaluating PPE needs:
Eye and face protection when there is a potential to encounter hazards such as flying debris, chemical
splashes and harmful light. Face shields used for splash protection must be used in conjunction with
either safety glasses or goggles.
PPE 12/14
Head Protection may be required when there is a danger of injury from falling objects from above, fixed
objects (i.e., low clearance) or electrical shock and burns.
Hand and arm protection may be required when skin may be exposed to harmful substances, chemical or
thermal burns, electrical dangers, bruises, abrasions, cuts or punctures, fractures and amputations.
Torso protection may be required when exposed to hot splashes from molten metals or other hot liquids,
impact from tools or machines or hazardous chemicals.
Hearing protection may be required when an employee is exposed to industrial noise above 85 dBA or
electrical work involving an arc flash hazard.
4. Care, Maintenance, Use and Limitations of PPE
A. Care and Maintenance of PPE
1. Reusable PPE must be kept in plastic bags or storage lockers to promote cleanliness
and prevent contamination or degradation.
2. Follow manufacturer’s instructions in cleaning and maintaining reusable PPE.
3. Replace defective or damaged PPE immediately.
4. Discard defective or damaged PPE.
B. Use of PPE
1. [insert responsible parties] will ensure employees wear required and properly fitted
PPE.
2. [insert responsible parties] will ensure PPE is used correctly for the intended
application.
3. [insert responsible parties]will ensure employees understand how to inspect, don,
doff, adjust and wear PPE.
C. Limitations of PPE
1. [insert responsible parties]will ensure employees understand PPE is designed for
specific hazards; however, PPE must be evaluated to ensure it protects against the
hazard as intended.
2. [insert responsible parties] will ensure employees understand that defective or
damaged PPE can have a negative impact, such as dirty or scratched safety glasses
or face shields can limit vision.
V. TRAINING
1. Initial and Annual Training
[insert responsible parties] will ensure awareness training will be provided to all employees upon initial
assignment and annually thereafter. Training will cover general PPE requirements and relevant facility-
specific PPE requirements. Awareness training documentation is maintained at [insert location or
electronic file path][a sample training form is attached]
PPE 12/14
2. Retraining
[insert responsible parties] will ensure retraining for employees must be completed when changes in the
workplace render previous training obsolete, or when the employee has not retained the required
skills/knowledge needed.
PPE 12/14
Sample PPE Hazard Assessment/Certification Form
&
Employee Training Certification
PPE 12/14
Personal Protective Equipment (PPE)
Hazard Assessment Survey and Analysis
The Following Hazards Have Been Noted
Part of Body
Hazard
Required PPE
Notes
 Penetration-sharp objects
 Leather/cut resistant gloves
 Penetration-animal bites
 Leather/cut resistant gloves
Hands
 Penetration-rough objects
 General purpose work gloves
 Chemical(s) __________
 Chemical resistant gloves;
 Type _________________
____________________
 Extreme cold
 Insulated gloves
 Extreme heat
 Heat/flame resistant gloves
 Blood or other body fluids
 Latex or nitrile gloves
 Electrical shock
 Insulated rubber gloves;
 Vibration-power tools
 Type _____________
 Other ______________
 Cotton, leather or anti-vibration
gloves
 Other __________________
 Impact-flying objects,
 Safety glasses w/side shields
 Glasses/goggles w/face shield
chips, sand or dirt
Eyes and Face
 Nuisance dust
 Impact goggles
 UV light-welding, cutting,
 Welding goggles
 Welding helmet/shield w/safety
torch brazing or soldering
 Chemical-splashing liquid
glasses & side shields
 Chemical-irritating mists
 Chemical goggles/ face shield
 Hot sparks-grinding
 Chemical splash goggles
 Splashing molten metal
 Safety glasses w/side shields
 Glasses/goggles w/face shield
Glare/High Intensity lights
 Safety goggles w/face shield
 Laser operations
 Shaded safety glasses
 Other ______________
 Laser spectacles or goggles
 Other __________________
 Ear muffs, plugs or
Ears
Exposure to noise levels
ear caps
( 85 dBA 8-hour TWA)
 Leather welding hood
 Exposure to sparks
 Other __________________
 Other ______________
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PPE 12/14

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