"Personal Protective Equipment Hazard Assessment Form - Nc State University"

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PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
PART I
Per OSHA 29 CFR 1910.132 “Subpart I”
INSTRUCTIONS: Print this form and keep the original for future hazard assessments. Use a copy as a guide for your walk-through survey.
It will help you identify the hazards in the work area. Once you’ve completed the form you are ready to select the appropriate PPE.
AREA ASSESSED:_________________________________JOB CLASSIFICATION:_______________________________
ASSESSOR______________________________________________DATE:_______________________________________
A
. HEAD HAZARDS:
Tasks that can present head hazards include: Working below other workers who are using tools, materials, or
other items which can fall: Working on or near energized electrical equipment: Working with or near chemicals: Working under, or near
equipment or processes which might cause materials, objects, or chemicals to fall or otherwise strike a worker’s head.
Circle the appropriate word for each hazard:
Burn
Yes
No
Description of hazard(s)____________________________________________________
Chemical Splash
Yes
No
________________________________________________________________________
Electrical Shock
Yes
No
________________________________________________________________________
Impact
Yes
No
________________________________________________________________________
Other(describe)_______________
N/A
________________________________________________________________________
(Transfer this data to section A. in Part II of this form)
B
. EYE HAZARDS:
Tasks that can cause eye hazards include: Working with or near chemicals: Chipping: Grinding: Sanding: Welding
and/or working with molten metals: Working in dusty environments: Woodworking: Furnace operation: Operation of stationary or hand-held
power tools: Using compressed air or gasses: Working beneath equipment or processes while looking up.
Circle the appropriate word for each hazard:
Chemicals
Yes
No
Description of hazard(s)_____________________________________________________
Dust, Fibers, Flyings
Yes
No
________________________________________________________________________
Heat
Yes
No
________________________________________________________________________
Impact
Yes
No
________________________________________________________________________
Light / Radiation
Yes
No
________________________________________________________________________
Other (describe) ______________N/A ________________________________________________________________________________
(Transfer this data to section B in Part II of this form)
C
. HAND HAZARDS:
Tasks that can present hand hazards include: Cutting material: Working with chemicals: Working with hot/cold
objects: Handling rough, sharp, splintered material.
Circle the appropriate word for each hazard:
Thermal extremes Yes
No
Description of hazard(s)_____________________________________________________________
Chemicals
Yes
No
________________________________________________________________________________
Cut, Abrasion
Yes
No
________________________________________________________________________________
Puncture
Yes
No
________________________________________________________________________________
Other (describe)__________ N/A
________________________________________________________________________________
(Transfer this data to section C in Part II of this form)
D
FOOT HAZARDS:
.
Tasks that can cause foot hazards include: Carrying or handling materials that can be dripped: Performing
manual materials handling tasks; Working with chemicals: Working in environments with sharp objects on floor: Working with machinery
that can drop objects on workers’ foot: Handling extremely heavy objects.
Check the appropriate word for each hazard:
Chemicals
Yes
No
Description of hazard(s)_____________________________________________________
Crushing
Yes
No
________________________________________________________________________
Impact
Yes
No
________________________________________________________________________
Puncture
Yes
No
________________________________________________________________________
Other (describe) __________________N/A
________________________________________________________________________
(Transfer this data to section D in Part II of this form)
PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT FORM
PART I
Per OSHA 29 CFR 1910.132 “Subpart I”
INSTRUCTIONS: Print this form and keep the original for future hazard assessments. Use a copy as a guide for your walk-through survey.
It will help you identify the hazards in the work area. Once you’ve completed the form you are ready to select the appropriate PPE.
AREA ASSESSED:_________________________________JOB CLASSIFICATION:_______________________________
ASSESSOR______________________________________________DATE:_______________________________________
A
. HEAD HAZARDS:
Tasks that can present head hazards include: Working below other workers who are using tools, materials, or
other items which can fall: Working on or near energized electrical equipment: Working with or near chemicals: Working under, or near
equipment or processes which might cause materials, objects, or chemicals to fall or otherwise strike a worker’s head.
Circle the appropriate word for each hazard:
Burn
Yes
No
Description of hazard(s)____________________________________________________
Chemical Splash
Yes
No
________________________________________________________________________
Electrical Shock
Yes
No
________________________________________________________________________
Impact
Yes
No
________________________________________________________________________
Other(describe)_______________
N/A
________________________________________________________________________
(Transfer this data to section A. in Part II of this form)
B
. EYE HAZARDS:
Tasks that can cause eye hazards include: Working with or near chemicals: Chipping: Grinding: Sanding: Welding
and/or working with molten metals: Working in dusty environments: Woodworking: Furnace operation: Operation of stationary or hand-held
power tools: Using compressed air or gasses: Working beneath equipment or processes while looking up.
Circle the appropriate word for each hazard:
Chemicals
Yes
No
Description of hazard(s)_____________________________________________________
Dust, Fibers, Flyings
Yes
No
________________________________________________________________________
Heat
Yes
No
________________________________________________________________________
Impact
Yes
No
________________________________________________________________________
Light / Radiation
Yes
No
________________________________________________________________________
Other (describe) ______________N/A ________________________________________________________________________________
(Transfer this data to section B in Part II of this form)
C
. HAND HAZARDS:
Tasks that can present hand hazards include: Cutting material: Working with chemicals: Working with hot/cold
objects: Handling rough, sharp, splintered material.
Circle the appropriate word for each hazard:
Thermal extremes Yes
No
Description of hazard(s)_____________________________________________________________
Chemicals
Yes
No
________________________________________________________________________________
Cut, Abrasion
Yes
No
________________________________________________________________________________
Puncture
Yes
No
________________________________________________________________________________
Other (describe)__________ N/A
________________________________________________________________________________
(Transfer this data to section C in Part II of this form)
D
FOOT HAZARDS:
.
Tasks that can cause foot hazards include: Carrying or handling materials that can be dripped: Performing
manual materials handling tasks; Working with chemicals: Working in environments with sharp objects on floor: Working with machinery
that can drop objects on workers’ foot: Handling extremely heavy objects.
Check the appropriate word for each hazard:
Chemicals
Yes
No
Description of hazard(s)_____________________________________________________
Crushing
Yes
No
________________________________________________________________________
Impact
Yes
No
________________________________________________________________________
Puncture
Yes
No
________________________________________________________________________
Other (describe) __________________N/A
________________________________________________________________________
(Transfer this data to section D in Part II of this form)
PART II
CERTIFICATION OF HAZARD ASSESSMENT
INSTRUCTIONS: Transfer information from Part I to the appropriate sections below. (1) Familiarize yourself with the potential hazards
and the types of PPE that are available to protect against the hazards. (2) Consider the magnitude and other characteristics of the hazard(s)
and environment; such as impact velocities, masses, projectile shape, strength of chemical compositions, concentrations of dusts, mists,
gasses, fumes, radiant energy intensities, etc. (3) Select PPE that ensures a greater level of protection than the minimum required to protect
workers from the hazards. Specify PPE by evaluative criteria, and/or manufacturer, model, size, and other applicable features. (4) Fit the
PPE to the worker, train the worker in PPE use and care. Ensure workers are aware of all limitations, warning labels, and other
characteristics of the PPE. Instruct employees on who to contact if they have problems or questions pertaining to their PPE.
BASED ON THE HAZARD ASSESSMENT FOR __________________________________THE FOLLOWING PPE IS REQUIRED:
(Job Classification)
A
. HEAD HAZARDS:
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
B.
EYE HAZARDS
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
C
. HAND HAZARDS
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
D
.
FOOT HAZARDS
JOB / TASK
REQUIRED PPE
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
________________________
___________________________
_________________________
Certification: I certify that this Hazard Evaluation was conducted as described above, in a good-faith
effort to comply with the applicable Hazard Assessment portions of 29 CFR 1910.132.
Signed____________________________________________Date_______________________________
(Adapted from an internet document posted by N. C. State University)

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