"Personal Protective Equipment Assessment Form - Ithaca College"

ADVERTISEMENT
ADVERTISEMENT

Download "Personal Protective Equipment Assessment Form - Ithaca College"

211 times
Rate (4.6 / 5) 10 votes
ITHACA COLLEGE – PERSONAL PROTECTIVE EQUIPMENT ASSESSMENT FORM
This form is intended to guide supervisors and managers in assessing their work place(s) for hazards that necessitate the use of personal protective equipment (PPE).
Once complete, send a copy of this form to EH&S for recommendations and assistance with PPE selection.
Department/Office: _________________________________________ Name & Job Title of Person Performing PPE Assessment: ____________________________________
Date of Assessment: ________________________________________
*Indicate in the Corresponding Box All Applicable Hazards for Each Job and/or Task Under Your Supervision*
Eye/Face
Head
Torso/Limbs
(2)
Hand
Respiratory
(flying particles or
(falling objects;
(splashing
chips; molten
(skin absorption of
flying objects;
(harmful dusts;
chemicals; flying
metal; liquid
harmful substances or
impact with
fogs; fumes; mists;
debris; abrasion,
Foot
chemicals; acidic
infectious materials;
heavy
gases; smokes;
cuts or
(heavy falling objects;
(1)
Hearing
or caustic liquids;
severe cuts or
equipment,
sprays; or vapors
lacerations;
Job Title & Task Description
heavy rolling objects;
chemical gases
(Noise above
lacerations; severe
machines, or
that can not be
temperature
compression/crushing;
vapors, or mists;
90 decibels)
abrasions; punctures;
other objects;
reduced to safe
extremes;
puncture hazard;
intense
chemical burns; thermal
electric shock
levels by ventilation
electric arc; low
electrical hazards
light/radiation;
burns; harmful
systems or other
visibility to
splashing of
temperatures; electric
engineering
vehicle traffic;
infectious
arc
controls)
other hazards to
materials
health)
Notes:
1 – Refer to the latest noise monitoring survey conducted by EH&S.
2 – An assessment of respiratory hazards has been conducted by EH&S. Use of a respirator requires prior medical clearance, specific training, and participation in the Ithaca College Respiratory Protection Program. Contact
EH&S if there is a question about whether a particular task requires the mandatory use of a respirator. Employees may not wear respirators (except dust masks) without being included in the Respiratory Protection Program.
Page ___________ of ___________
ITHACA COLLEGE – PERSONAL PROTECTIVE EQUIPMENT ASSESSMENT FORM
This form is intended to guide supervisors and managers in assessing their work place(s) for hazards that necessitate the use of personal protective equipment (PPE).
Once complete, send a copy of this form to EH&S for recommendations and assistance with PPE selection.
Department/Office: _________________________________________ Name & Job Title of Person Performing PPE Assessment: ____________________________________
Date of Assessment: ________________________________________
*Indicate in the Corresponding Box All Applicable Hazards for Each Job and/or Task Under Your Supervision*
Eye/Face
Head
Torso/Limbs
(2)
Hand
Respiratory
(flying particles or
(falling objects;
(splashing
chips; molten
(skin absorption of
flying objects;
(harmful dusts;
chemicals; flying
metal; liquid
harmful substances or
impact with
fogs; fumes; mists;
debris; abrasion,
Foot
chemicals; acidic
infectious materials;
heavy
gases; smokes;
cuts or
(heavy falling objects;
(1)
Hearing
or caustic liquids;
severe cuts or
equipment,
sprays; or vapors
lacerations;
Job Title & Task Description
heavy rolling objects;
chemical gases
(Noise above
lacerations; severe
machines, or
that can not be
temperature
compression/crushing;
vapors, or mists;
90 decibels)
abrasions; punctures;
other objects;
reduced to safe
extremes;
puncture hazard;
intense
chemical burns; thermal
electric shock
levels by ventilation
electric arc; low
electrical hazards
light/radiation;
burns; harmful
systems or other
visibility to
splashing of
temperatures; electric
engineering
vehicle traffic;
infectious
arc
controls)
other hazards to
materials
health)
Notes:
1 – Refer to the latest noise monitoring survey conducted by EH&S.
2 – An assessment of respiratory hazards has been conducted by EH&S. Use of a respirator requires prior medical clearance, specific training, and participation in the Ithaca College Respiratory Protection Program. Contact
EH&S if there is a question about whether a particular task requires the mandatory use of a respirator. Employees may not wear respirators (except dust masks) without being included in the Respiratory Protection Program.
Page ___________ of ___________