Hazard Assessment Certification Form - Hawaii

This printable "Hazard Assessment Certification Form" is a document issued by the Hawaii Department of Human Resources Development specifically for Hawaii residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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State of Hawaii
HAZARD ASSESSMENT CERTIFICATION
Department: __________________________________________
Job Title of Employee: _____________________________________________
Division/Branch: ______________________________________
Position Number: _________________________________________________
Baseyard: ____________________________________________
Evaluated By (Print Name): ________________________________________
Work Unit: ___________________________________________
Position: _________________________________ Phone: ________________
Position Location (island, city): ___________________________
Duties: ___ Mostly outdoors; ___ Mostly indoors
Task, Activity, Hazard Source (1)
Assessment of Hazard (2)
Protection (3)
Hazard Assessment; Type of protection required for tasks shown above:
Base:  Impact/compression
Additional:  High cut - height:
6"____; 8" ____ ; Other: ______________
 Metatarsal
 Slip resistant
 Electrical
 Water resistant
 Sole Protection
 Heat resistant (soles)
 Water resistant boots
 Fire resistant (welding)
Impact and compression requirement:
30 _____, 50 _____, or 75 _____ .
Person certifying assessment: ______________________________
___________________________________
______________________
Print Name (if different from above)
Signature
Date
State of Hawaii
HAZARD ASSESSMENT CERTIFICATION
Department: __________________________________________
Job Title of Employee: _____________________________________________
Division/Branch: ______________________________________
Position Number: _________________________________________________
Baseyard: ____________________________________________
Evaluated By (Print Name): ________________________________________
Work Unit: ___________________________________________
Position: _________________________________ Phone: ________________
Position Location (island, city): ___________________________
Duties: ___ Mostly outdoors; ___ Mostly indoors
Task, Activity, Hazard Source (1)
Assessment of Hazard (2)
Protection (3)
Hazard Assessment; Type of protection required for tasks shown above:
Base:  Impact/compression
Additional:  High cut - height:
6"____; 8" ____ ; Other: ______________
 Metatarsal
 Slip resistant
 Electrical
 Water resistant
 Sole Protection
 Heat resistant (soles)
 Water resistant boots
 Fire resistant (welding)
Impact and compression requirement:
30 _____, 50 _____, or 75 _____ .
Person certifying assessment: ______________________________
___________________________________
______________________
Print Name (if different from above)
Signature
Date
Hazard Assessment - Foot Protection Form
Occupational safety and health (OSH) rules require employers to identify hazards in the workplace that
cause or likely to cause employee injuries or illness. The personal protective equipment (PPE) revision focuses
on eye and face, head, foot, and arm protection. Although the process contained herein addresses foot
protection, the basic hazard assessment process can be used for other areas. However, OSH rules emphatically
state that PPE should not be used as a substitute for engineering, work practices, and/or administrative controls.
PPE should be used in conjunction with these controls to provide employee safety and health in the workplace.
A general five step procedure that is effective and not overly burden-some can be used to complete the
requirements. The Hazard Assessment Certification (Foot Protection) form facilitates the process. The steps
are:
1.
Complete the location demographics section of the form. The rules call for assessment of a
particular type of work activity at a given location. The assessment can not be of all positions (or
work duties) of a baseyard or department island or statewide. An assessment of same positions that
have identical duties and responsibilities at a specific baseyard is permissible.
2.
Perform assessment by initiating a walk-through of the work site in order to identify tasks (column
1) with potential sources of injury such as: carry 45 pound boxes, roll/move 55 gallon drums,
repair/install junction boxes, inspect construction sites, clean animal shelters or mowing grass in
open fields. List all tasks that indicate a source of potential foot injury.
In column 2 indicate the corresponding hazard from column 1, such as: crush feet, crush feet/smash
toes, electrical shock, smash feet/sole puncture, animal fecal infection/slippery/continuous wet feet
and impact/flying rocks. (Crush/smash feet potential would indicate a need for metatarsal foot
protection.)
3.
For column 3, review data of each hazard (in column 2) to determine the type of foot protection
required. For example, should the hazard potential be electric shock the foot protection required is
electric resistance shoes. If glass and nails be identified as the hazard, puncture resistant shoes
would be required.
4.
Transpose table data to define hazard in the hazard assessment section of the form. Check-off all
that apply. Specify additional foot protection requirements by checking the additional protection as
required. Where high tops are required indicate the height of high top protection required - 6 or 8
inches. Where requirements are not readily listed on the form use the "Other" segment of the form
to list the protection required. Also indicate the level of impact and compression required - 30, 50,
or 75 foot-pounds (ft/lbs) corresponding to the design of the "safety toe" to resist corresponding
ft./lbs. (foot/pounds) of crush or impact resistance to maintain specified toe clearance. Note: more
shoes are available at the 75 ft/lbs level of protection and the availability of shoes (type and style)
decreases as protection requirements increase.
5.
Complete certification requirements by printing the name of evaluator, and with the evaluator
signing and dating the form. Transpose applicable data to the Authorization form. Where more
than one basic requirement is indicated, care must be exercised to ensure only one allowance and
impact/compression (I/C ) data are shown where simultaneous protection is required - the higher
allowance and I/C data (as obtained from the assessment form.). Also note that only the most
frequent additional requirements are shown on the table. Other additional requirements must be
listed in the Other Requirement section of the form.

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