"Personal Protective Equipment Form (Short Version)"

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Personal Protective Equipment Form (Short Version) is a 3-page legal document that was released by the U.S. Department of Labor - Occupational Safety & Health Administration on March 7, 2011 and used nation-wide.

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PERSONAL PROTECTIVE EQUIPMENT (PPE)
(SHORT VERSION)
WELCOME!
This sample program is provided to assist you as an employer in developing programs tailored
to your own operation. We encourage you to copy, expand, modify and customize this sample
as necessary to accomplish this goal. We have an alternative, longer, “PPE” document
available that you may also want to consider using.
This document is provided as a compliance aid, but does not constitute a legal interpretation of
OSHA Standards, nor does it replace the need to be familiar with, and follow, the actual OSHA
Standards (including any North Carolina specific changes.) Though this document is intended
to be consistent with OSHA Standards, if an area is considered by the reader to be inconsistent,
the OSHA standard should be followed. Of course, we welcome your comments and feedback!
Remember: A written safety/health program is only effective if it is put into place!
PERSONAL PROTECTIVE EQUIPMENT (PPE)
(SHORT VERSION)
WELCOME!
This sample program is provided to assist you as an employer in developing programs tailored
to your own operation. We encourage you to copy, expand, modify and customize this sample
as necessary to accomplish this goal. We have an alternative, longer, “PPE” document
available that you may also want to consider using.
This document is provided as a compliance aid, but does not constitute a legal interpretation of
OSHA Standards, nor does it replace the need to be familiar with, and follow, the actual OSHA
Standards (including any North Carolina specific changes.) Though this document is intended
to be consistent with OSHA Standards, if an area is considered by the reader to be inconsistent,
the OSHA standard should be followed. Of course, we welcome your comments and feedback!
Remember: A written safety/health program is only effective if it is put into place!
______________________________________________
Company Name
Personal Protective Equipment (PPE) Hazard Assessment
Location/ Jobs
Potential Hazards
Body Parts
Required PPE
Indicate Department, Job Title,
1 Sharp/ Abrasive Objects
18 Head
A Hard Hat/ Bump Cap
Equipment, Location or other
2 Flying Particles
19 Face
B Safety Glasses
identification of the task for
3 Falling Objects
20 Eye(s)
C Chemical Splash Goggles
which PPE is required:
4 Acidic/ Caustic Chemicals
21 Ear(s)
D Face Shield
5 Toxic Chemicals
22 Respiratory System
E Welding Helmet
6 Chemical Absorption
23 Trunk
F Ear Plugs
7 Temperature Extremes
24 Arm(s)
G Ear Muffs
8 Sparks/ Hot Particles
25 Hand(s)
H Personal Fall Protection (list)
9 Light Radiation
26 Finger(s)
I Gloves (list type)
10 Chemical Gases/ Vapors
27 Leg(s)
J Shoes/ Boots (list type)
11 Wet/ Slippery Surfaces
28 Foot/ Feet
K Respirator (list type)
12 Electrical Hazards
29 Toe(s)
L High Vis Vest/Clothing
13 Biohazards
30 Other (describe)
M Gauntlets (list type)
14 Noise
N Apron (list type)
15 Vehicular Traffic
O Coat/ Coverall
16 Fall from Heights
P Other (list type)
17 Other (describe)
*Potential Hazards
*Body Part(s)
*PPE Required
Example: Disinfection
Caustic chemicals
Hands
Heavy duty latex glove
*Insert description or corresponding #.
CERTIFICATION
This hazard assessment has been performed to determine the type of PPE required for each affected employee.
The assessment included a walk-through survey, specific job analysis, review of accident statistics, review of safety
equipment selection guidelines, and selection of appropriate required PPE.
Assessment Certified by (Supervisor) ____________________
Date _____________________
Company Name
2
Certification of Employee Training on the Proper Use of Personal Protective Equipment
Instructor: _________________________________
Date: _______________
Training Topics Covered:
Company/ employee responsibilities
Work area hazards
How PPE will protect
When PPE should be worn
What PPE should be worn
How to don, doff, assure proper fit, adjust, and wear properly
Limitations of the PPE
Proper care, maintenance, cleaning (sanitation)
Reporting and replacement of worn damaged PPE
Useful life, and
Proper disposal of PPE
The following employees have received training on their assigned PPE and have demonstrated an understanding of
that PPE:
Department
Printed Name
Signature
Revised 03/07/2011
3
Ppe Hazard Assessment Form U.S. Department of Labor - Occupational Safety & Health Administration Assessment Template United States Federal Legal Forms United States Legal Forms

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