Tool: PPE Hazard Assessment Form

PPE HAZARD ASSESSMENT FORM

Use and modify this sample form to help you determine what hazards workers are exposed to and what PPE must be worn to protect them.

  • If you check YES, determine if the hazard can be eliminated.
  • If NO, can the method or equipment be changed to eliminate the hazard?
    • If so, consider doing it.
  • If the hazard can’t be eliminated, would adding a guard protect employees from the hazard, e.g., machine guards?
    • If this is the case, indicate a guard is being installed.
  • In the last column, list the type of PPE the worker will be required to use.

 

PERSONAL PROTECTIVE EQUIPMENT HAZARD ASSESSMENT

 

Facility____________________  Dept.________________ Date_________

Supervisor _________________   Job ______________________________

 

EYES & FACE
Hazard Yes No Eliminated, Guarded? PPE Required
Flying particles        
Molten metals        
Liquid chemicals        
Acids        
Caustic liquids        
Chemical gases or vapors        
Light radiation        
Other        
Head
Hazard Yes No Eliminated, Guarded? PPE Required
Flying objects        
Falling objects        
Work done overhead        
Elevated conveyors        
Hitting against fixed object        
Forklift hazards        
Exposed electrical conductors        
Other        
Feet
Hazard Yes No Eliminated, Guarded? PPE Required
Flying objects        
Rolling objects        
Objects piercing sole        
Electrical hazards        
Wet, slippery or hot surfaces        
Chemical exposure        
Environmental        
Other        
Hands
Hazard Yes No Eliminated, Guarded? PPE Required
Skin absorption        
Cuts or lacerations        
Abrasions        
Punctures        
Chemical burns        
Thermal burns        
Temperature extremes        
Other        
Respiratory
Hazard Yes No Eliminated, Guarded? PPE Required
Dusts        
Fogs        
Fumes        
Mists        
Smokes        
Sprays        
Vapors        
Other        
Torso
Hazard Yes No Eliminated, Guarded? PPE Required
Hot metals        
Cuts        
Acids        
Radiation        
Other        
Comments:

 

 

 

 

Certification


This hazard assessment has been performed to determine the required type of PPE for each affected worker.

The assessment includes:

  • Walk-through survey
  • Specific job analysis
  • Review of accident statistics
  • Review of safety equipment selection guideline materials
  • Selection of appropriate required PPE

Assessment Certified by (Supervisor) ______________________ Date _____________________