Personal Protective Equipment Hazard Assessment Form

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Personal Protective Equipment
Hazard Assessment Form
Location________________________________________________Department____________________________________________
Job Task_______________________________Assessment Conducted By___________________________________Date__________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Eye and Face
(E= Eliminated Hazard, G= Hazard Already Guarded)
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Flying Particles
_____
_____
______
Safety Glasses _____ w/ side shields
2- Liquid Chemicals
_____
_____
______
Splash-tight Goggles
3- Losing Grip on Hand Tools
_____
_____
______
Cut/Tear Resistant Gloves (i.e. Mechanix Gloves)
4- Cutting, Drilling, Grinding, Chipping, Hammering
_____
_____
______
Impact Goggles or Face Shield
5- Welding, Soldering
_____
_____
______
Welding Helmet
6- Sanding
_____
_____
______
Dust-tight Goggles
7- Painting
_____
_____
______
Face Shield
8- Computer Work
_____
_____
______
Glare Screen/ Position of Monitor
Other_____________________________________
Head
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Falling Objects from Above (shelving, lifts, etc)
_____
_____
______
Protective Helmet, Hard Hat
2- Flying Particles
_____
_____
______
Organized Shelving w/ Edge Guard or Chain
3- Moving Objects via Hoist, Forklift (above head)
_____
_____
______
4 Sided Materials Basket, Encapsulated Load on Forklift
4- Working Under Vehicle
_____
_____
______
Lift Safety Controls Engaged At All Times
5- Strike Against Fixed Object
_____
_____
______
Other_____________________________________
Personal Protective Equipment
Hazard Assessment Form
Location________________________________________________Department____________________________________________
Job Task_______________________________Assessment Conducted By___________________________________Date__________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Eye and Face
(E= Eliminated Hazard, G= Hazard Already Guarded)
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Flying Particles
_____
_____
______
Safety Glasses _____ w/ side shields
2- Liquid Chemicals
_____
_____
______
Splash-tight Goggles
3- Losing Grip on Hand Tools
_____
_____
______
Cut/Tear Resistant Gloves (i.e. Mechanix Gloves)
4- Cutting, Drilling, Grinding, Chipping, Hammering
_____
_____
______
Impact Goggles or Face Shield
5- Welding, Soldering
_____
_____
______
Welding Helmet
6- Sanding
_____
_____
______
Dust-tight Goggles
7- Painting
_____
_____
______
Face Shield
8- Computer Work
_____
_____
______
Glare Screen/ Position of Monitor
Other_____________________________________
Head
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Falling Objects from Above (shelving, lifts, etc)
_____
_____
______
Protective Helmet, Hard Hat
2- Flying Particles
_____
_____
______
Organized Shelving w/ Edge Guard or Chain
3- Moving Objects via Hoist, Forklift (above head)
_____
_____
______
4 Sided Materials Basket, Encapsulated Load on Forklift
4- Working Under Vehicle
_____
_____
______
Lift Safety Controls Engaged At All Times
5- Strike Against Fixed Object
_____
_____
______
Other_____________________________________
______________________________________________________________________________________________________________________
Hands/Arms
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Losing Grip on Hand Tools (Cuts/Abrasions)
_____
_____
______
Tool guards, Blade guards, Torque Rods
2- Striking Against Sharp Part (Cuts/Abrasions)
_____
_____
______
Cut/Tear Resistant Gloves (i.e. Mechanix Gloves)
3- Punch Press, Shear, Lathe (Cuts)
_____
_____
______
Equipment Guards and Machine Controls
Cut Resistant Sleeves for Sheet Metal Work
4- Liquid Chemicals
_____
_____
______
Dust/Splash Tight Goggles
5- Thermal Burns (Hot Surfaces)
_____
_____
______
Heat Resistant Gloves, Wait for Engine Cooling
6- Electrical, Pneumatic, Hydraulic Hazards
_____
_____
______
Lock Out/Tag Out Procedure in Place
7- Computer Work
_____
_____
______
Ergonomic Positioning of Wrist/Arms
8- Caught Between Moving Objects
_____
_____
______
Other________________________________________
Feet/Legs
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Falling or Rolling Objects on the Floor
_____
_____
______
Secure Equipment
Steel Toed Shoes, Shin Protectors
2- Objects on Floor Obstructing Walking/Working Surface
_____
_____
______
Improve Housekeeping
3- Objects Piercing the Shoe Sole
_____
_____
______
Appropriate Footwear for Job Task
Secure Sharp Parts
4- Wet or Slippery Floor Surfaces
_____
_____
______
Improve Floor Cleaning
Improve Drainage
Enforce Spill Clean-up
5- Carrying Heavy Objects
_____
_____
______
Steel Toed Shoes, Shin Protectors
6- Chemical/Thermal Burns
_____
_____
______
Other________________________________________
Body/Whole
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Lifting Tires
_____
_____
______
Tire Lift
Tire Moving Device
Adjust Tire Process
2- Handling Transmissions, Engines, Other Heavy Parts
_____
_____
______
Use Mechanical Moving Devices (hoist ,forklift, cart, etc)
3- Struck by Moving Vehicle
_____
_____
______
Directional Traffic Patterns
Back-Up Policy
Reflective Vests
4- Acid Containing Products
_____
_____
______
Acid Protecting Splash Suits
5- Extreme Heat
_____
_____
______
Follow Company Heat Stress Plan
6- Work at Heights
_____
_____
______
Fall Protection
Appropriate Ladders/Scaffolding
8- Computer Work
_____
_____
______
Ergonomic Equipment__________________________
Respiratory
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Painting with Solvent Based Paints containing Isocyanates _____
_____
______
Supplied Air w/ Full Hood
PAPR w/ Full Hood
2- Sanding
_____
_____
______
Dust Mask
3- Cleaning with Harmful Chemicals
_____
_____
______
Follow MSDS for Respiratory Controls
4- Vehicle Body Repairs with Fiberglass-Based Products
_____
_____
______
Follow MSDS for Respiratory Controls
5- Groundsckeeping using pesticides
_____
_____
______
Follow MSDS for Respiratory Controls
6- Brake Dust from Asbestos Containing Brake Pads
_____
_____
______
Negative Pressure HEPA Self Enclosed Vacuum System
Wet Down Method
Miscellaneous
Is there any danger from the following hazards?
Yes
No
E, G
Identify Administrative or PPE Controls Needed
1- Loud Noise (generator, fans, sanding, tool use)
_____
_____
______
Ear Plugs
Ear Muffs
Noise Encapsulation
1- Contact with Bodily Fluids
_____
_____
______
Cut Resistant Gloves when Reaching under Seats
Latex Gloves if involved in Emergency Response
2- Groundskeeping/Snow Removal
_____
_____
______
Guards on all equipment
Staff Trained in Equipment
Usage
4- Other____________________________________
_____
_____
______
Other________________________________________
Corrective Actions
If any hazards noted above could be eliminated, please note the action taken below.
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________

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