ࡱ> W  bjbjɪ kȣeȣe)   OOOOO$sssP s)I8 ))))*n<+$`+GGGGGGG$KMHOt+**t+t+HOO))H,,,t+:O)O)G,t+G,,DDG)G+: F&GH0)I2FjSN+vSNLGSNOG,t+t+,t+t+t+t+t+HH^,vt+t+t+)It+t+t+t+SNt+t+t+t+t+t+t+t+t+  : Hazard Assessment For PPE This tool can help you do a hazard assessment to see if you need to use personal protective equipment (PPE) by identifying activities that may create hazards. The activities are grouped according to what part of the body might need PPE. You can make copies, modify and customize it to fit the specific needs of your particular work place, or develop your own form that is appropriate to your work environment. This tool can also serve as written certification that you have done a hazard assessment. Make sure that the blank fields at the beginning of the checklist (indicated by *) are filled out (see below, Instructions #4). Instructions: Do a walk-through survey of each work area and job/task. Read through the list of work activities in the first column, putting a check next to the activities performed in that work area or job. Read through the list of hazards in the second column, putting a check next to the hazards to which employees may be exposed while performing the work activities or while present in the work area. (for e.g., work activity: chopping wood; work-related exposure: flying particles). Decide how you are going to control the hazards. Try considering engineering, work place, and/or administrative controls to eliminate or reduce the hazards before resorting to using PPE. If the hazard cannot be eliminated without using PPE, indicate which type(s) of PPE will be required to protect your employee from the hazard. Make sure that you complete the following fields on the form (indicated by *) to certify that a hazard assessment was done: *Name of your work place *Address of the work place where you are doing the hazard assessment *Name of person certifying that a workplace hazard assessment was done *Date the hazard assessment was done PPE Hazard Assessment Certification Form *Name of work place: __________________________________ *Assessment conducted by: _________________________ *Work place address: __________________________________ *Date of assessment: _______________________________ Work area(s): _________________________________________ Job/Task(s): _______________________________________ *Required for certifying the hazard assessment. Use a separate sheet for each job/task or work area EYESWork activities, such as:  FORMCHECKBOX  abrasive blasting  FORMCHECKBOX  sanding  FORMCHECKBOX  chopping  FORMCHECKBOX  sawing  FORMCHECKBOX  cutting  FORMCHECKBOX  grinding  FORMCHECKBOX  drilling  FORMCHECKBOX  hammering  FORMCHECKBOX  welding  FORMCHECKBOX  punch press operations  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  airborne dust  FORMCHECKBOX  flying particles  FORMCHECKBOX  blood splashes  FORMCHECKBOX  hazardous liquid chemicals  FORMCHECKBOX  intense light  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Safety glasses  FORMCHECKBOX  Side shields  FORMCHECKBOX  Safety goggles  FORMCHECKBOX  Dust-tight  FORMCHECKBOX  Shading/Filter (# FORMTEXT      ) goggles  FORMCHECKBOX  Welding shield  FORMCHECKBOX  Other:  FORMTEXT       FACEWork activities, such as:  FORMCHECKBOX  cleaning  FORMCHECKBOX  foundry work  FORMCHECKBOX  cooking  FORMCHECKBOX  welding  FORMCHECKBOX  siphoning  FORMCHECKBOX  mixing  FORMCHECKBOX  painting  FORMCHECKBOX  pouring molten  FORMCHECKBOX  dip tank operations metal  FORMCHECKBOX  other  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  hazardous liquid chemicals  FORMCHECKBOX  extreme heat/cold  FORMCHECKBOX  potential irritants:  FORMTEXT        FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Face shield  FORMCHECKBOX  Shading/Filter (# FORMTEXT      )  FORMCHECKBOX  Welding shield  FORMCHECKBOX  Other:  FORMTEXT       HEADWork activities, such as:  FORMCHECKBOX  building maintenance  FORMCHECKBOX  confined space operations  FORMCHECKBOX  construction  FORMCHECKBOX  electrical wiring  FORMCHECKBOX  walking/working under catwalks  FORMCHECKBOX  walking/working under conveyor belts  FORMCHECKBOX  walking/working under crane loads  FORMCHECKBOX  utility work  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  beams  FORMCHECKBOX  pipes  FORMCHECKBOX  exposed electrical wiring or components  FORMCHECKBOX  falling objects  FORMCHECKBOX  machine parts  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Protective Helmet  FORMCHECKBOX  Type A (low voltage)  FORMCHECKBOX  Type B (high voltage)  FORMCHECKBOX  Type C  FORMCHECKBOX  Bump cap (not ANSI-approved)  FORMCHECKBOX  Hair net or soft cap  FORMCHECKBOX  Other:  FORMTEXT       HANDS/ARMSWork activities, such as:  FORMCHECKBOX  baking  FORMCHECKBOX  material handling  FORMCHECKBOX  cooking  FORMCHECKBOX  sanding  FORMCHECKBOX  grinding  FORMCHECKBOX  sawing  FORMCHECKBOX  welding  FORMCHECKBOX  hammering  FORMCHECKBOX  working with glass  FORMCHECKBOX  using computers  FORMCHECKBOX  using knives  FORMCHECKBOX  dental and health care services  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  blood  FORMCHECKBOX  irritating chemicals  FORMCHECKBOX  tools or materials that could scrape, bruise, or cut  FORMCHECKBOX  extreme heat/cold  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Gloves  FORMCHECKBOX  Chemical resistance  FORMCHECKBOX  Liquid/leak resistance  FORMCHECKBOX  Temperature resistance  FORMCHECKBOX  Abrasion/cut resistance  FORMCHECKBOX  Slip resistance  FORMCHECKBOX  Protective sleeves  FORMCHECKBOX  Other:  FORMTEXT       FEET/LEGSWork activities, such as:  FORMCHECKBOX  building maintenance  FORMCHECKBOX  construction  FORMCHECKBOX  demolition  FORMCHECKBOX  food processing  FORMCHECKBOX  foundry work  FORMCHECKBOX  logging  FORMCHECKBOX  plumbing  FORMCHECKBOX  trenching  FORMCHECKBOX  use of highly flammable materials  FORMCHECKBOX  welding  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  explosive atmospheres  FORMCHECKBOX  explosivSV   : G X m @Sxy/i278PRSabcwxjhZUjhZU hZ\hZ5CJ\aJhZCJaJhZ5\aJ hZaJ hZ5\ hZ5CJ hZ>*hQhZ5CJ\ hZ5CJhZB*CJph h*jhZUjhZUjhZUjhZUhZCJ^JaJjhZUj'hZUhZ0pRTPFH LN  !$If  !x$If  !$If*,@BDNPRT,.0PRnprݷݱujhZUjhZUj hZUjhZUj%hZU hZ>* hZaJ jhZ>*U\mHnHujhZ>*U\ hZ>*\jhZ>*U\hZjhZUj;hZU)   468BDFH:<>bdݷ豬윗vkj# hZUj hZUj; hZUj hZU hZ\ hZ5jS hZU hZ>* hZaJ jhZ>*U\mHnHujhZ>*U\ hZ>*\jhZ>*U\hZjhZUjihZU* ">$&:<>HJLNPZ\̾ӭ̨̄ӭ~yy hZ>* hZCJj hZ>*U\ji hZUj hZU hZ\ jhZ>*U\mHnHuj hZ>*U\ hZ>*\jhZ>*U\j hZUjhZUj hZUhZ,NPZrl$IfkdS$$IfT+F=$9hB)09    2+44 +aTZ\t^Rl}}}}}}}}}}}}}  !$Ifvkd$$IfT+499  0944 +af4p T &(*@B^`btv:<>^`|~jhZUjQhZUjhZUjihZUjhZUjhZUj hZUjhZUj%hZUhZjhZUjhZU0  NPRTprtDFZ\^hjln(ɽŲŽŧŽŜŽŃujhZ>*U\jhZUj hZ>*U\jhZUj#hZUjhZUjhZUhZ hZ>* jhZ>*U\mHnHuj9hZ>*U\ hZ>*\jhZ>*U\.,L  !$If$If  !x$If  !$If (46RTV\bd "68:DFLNjlnſſvkjhZU jhZ>*U\mHnHuj;hZ>*U\ hZ>*\jhZ>*U\jhZUjShZCJU hZCJjhZCJU hZ>*jhZU hZ\ hZ5jkhZUjhZUhZ'*,.0LNP~    . / = > ? _ ` n ݷ豬{pj=hZUjhZUjUhZUjhZUjmhZU hZ>* hZ\ hZCJ jhZ>*U\mHnHujhZ>*U\ hZ>*\jhZ>*U\hZjhZUj%hZU+ri $$Ifa$kd$$IfT+F=$9hB)09    2+44 +aT.~ . _ ""D"t"}}}}}}}}}}}}}  !$Ifvkd$$IfT+499  0944 +af4p Tn o p !!!!" 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Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Safety shoes or boots  FORMCHECKBOX  Toe protection  FORMCHECKBOX  Metatarsal protection  FORMCHECKBOX  Electrical protection  FORMCHECKBOX  Heat/cold protection  FORMCHECKBOX  Puncture resistance  FORMCHECKBOX  Chemical resistance  FORMCHECKBOX  Anti-slip soles  FORMCHECKBOX  Leggings or chaps  FORMCHECKBOX  Foot-Leg guards  FORMCHECKBOX  Other:  FORMTEXT       BODY/SKINWork activities such as:  FORMCHECKBOX  baking or frying  FORMCHECKBOX  battery charging  FORMCHECKBOX  dip tank operations  FORMCHECKBOX  fiberglass installation  FORMCHECKBOX  irritating chemicals  FORMCHECKBOX  sawing  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  chemical splashes  FORMCHECKBOX  extreme heat/cold  FORMCHECKBOX  sharp or rough edges  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Vest, Jacket  FORMCHECKBOX  Coveralls, Body suit  FORMCHECKBOX  Raingear  FORMCHECKBOX  Apron  FORMCHECKBOX  Welding leathers  FORMCHECKBOX  Abrasion/cut resistance  FORMCHECKBOX  Other:  FORMTEXT       BODY/WHOLE 1Work activities such as:  FORMCHECKBOX  building maintenance  FORMCHECKBOX  construction  FORMCHECKBOX  logging  FORMCHECKBOX  utility work  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  working from heights of 10 feet or more  FORMCHECKBOX  working near water  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, use:  FORMCHECKBOX  Fall Arrest/Restraint: Type:  FORMTEXT        FORMCHECKBOX  PFD: Type:  FORMTEXT        FORMCHECKBOX  Other:  FORMTEXT       *(See Footnote 1) LUNGS/RESPIRATORY 1Work activities such as:  FORMCHECKBOX  cleaning  FORMCHECKBOX  pouring  FORMCHECKBOX  mixing  FORMCHECKBOX  sawing  FORMCHECKBOX  painting  FORMCHECKBOX  fiberglass installation  FORMCHECKBOX  compressed air or gas operations  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  irritating dust or particulate  FORMCHECKBOX  irritating or toxic gas/vapor  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? Yes  FORMCHECKBOX  No  FORMCHECKBOX  *(See Footnote 1)EARS/HEARING 1Work activities such as:  FORMCHECKBOX  generator  FORMCHECKBOX  grinding  FORMCHECKBOX  ventilation fans  FORMCHECKBOX  machining  FORMCHECKBOX  motors  FORMCHECKBOX  routers  FORMCHECKBOX  sanding  FORMCHECKBOX  sawing  FORMCHECKBOX  pneumatic equipment  FORMCHECKBOX  punch or brake presses  FORMCHECKBOX  use of conveyors  FORMCHECKBOX  other:  FORMTEXT       Work-related exposure to:  FORMCHECKBOX  loud noises  FORMCHECKBOX  loud work environment  FORMCHECKBOX  noisy machines/tools  FORMCHECKBOX  punch or brake presses  FORMCHECKBOX  other:  FORMTEXT       Can hazard be eliminated without the use of PPE? 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