Sample personal protective equipment hazard assessment certification form

Found in the OSHA General Industry Standard 29 CFR 1910.132 is the requirement for employers to conduct a workplace assessment of the hazards that may be present where personal protective equipment (PPE) will be used to protect workers. The OSHA standard requires the employer show the workplace assessment was performed through a written certification that identifies the workplace evaluated; the person certifying the assessment was performed and the dates the assessment took place.

Performing the assessment

For each job task, or area of a facility, complete a separate certification form. The assessment should be completed by an employee who is familiar with the type of work performed, the hazards associated with the task or in the area and the proper PPE that should be used to protect employees.

Training

Workers need to be trained on the proper use, fitting, cleaning and storage of any PPE they may be required to use for protection. When training employees a written training certification should also be completed and maintained on file.

PPE hazard assessment certification form

*Name of work place: __________________________________ *Assessment conducted by: _____________________

*Work place address: __________________________________ *Date of assessment:___________________________

*Work area(s):________________________________________ *Job/Task(s): _________________________________

Eyes

Work activities, such as:

Abrasive
Blasting
Chopping
Cutting
Drilling
Welding
Punch press operations
Other: _________________________________

Work-related exposure to:

Airborne dust
Flying particles
Blood splashes
Hazardous liquid chemicals
Intense light
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Safety glasses
Safety goggles
Shading/filter (#____)
Welding shield
Other: _________________________________

Face

Work activities, such as:

Cleaning
Cooking
Siphoning
Painting
Dip tank operations
Other: _________________________________

Work-related exposure to:

Hazardous liquid chemicals
Extreme heat/cold potential irritants: ______________________
Other: ______________________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Face shield
Shading/filter (#____)
Welding shield
Other: _________________________________

*Required for certifying the hazard assessment. Use a separate sheet for each job/task or work area.

Head

Work activities, such as:

Building maintenance
Confined space operations
Construction
Electrical wiring
Walking/working under catwalks
Walking/working under conveyor belts
Walking/working under crane loads
Utility work
Other: _________________________________

Work-related exposure to:

Beams
Pipes
Exposed electrical wiring or components
Falling objects
Machine parts
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Protective helmet
- Type A (low voltage)
- Type B (high voltage)
- Type C
- Bump cap (not ANSI-approved)
Hair net or soft cap
Other: _________________________________

Hands / arms

Work activities, such as:

Baking
Cooking
Grinding
Welding
Working with glass
Using computers
Using knives
Dental and health care services
Other: _________________________________

Work-related exposure to:

Blood
Irritating chemicals
Tools or materials that could scrape, bruise, or cut
Extreme heat/cold
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Gloves
- Chemical resistance
- Liquid/leak resistance
- Temperature resistance
- Abrasion/cut resistance
- Slip resistance
Protective sleeves
Other: _________________________________

Feet / legs

Work activities, such as:

Building maintenance
Construction
Demolition
Food processing
Foundry work
Logging
Plumbing
Trenching
Use of highly flammable materials
Welding
Other: _________________________________

Work-related exposure to:

Explosive atmospheres
Explosives
Exposed electrical wiring or components
Heavy equipment
Slippery surfaces
Tools
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Safety shoes or boots
- Toe protection
- Electrical protection
- Puncture resistance
- Anti-slip soles
- Heat/cold protection
- Chemical resistance
Leggings or chaps
Foot-leg guards
Other: _________________________________

Body / skin

Work activities, such as:

Baking or frying
Battery charging
Dip tank operations
Fiberglass installation
Irritating chemicals
Sawing
Other: _________________________________

Work-related exposure to:

Chemical splashes
Extreme heat/cold
Sharp or rough edges
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Vest, Jacket
Coveralls, Body suit
Raingear
Apron
Welding leathers
Abrasion/cut resistance
Other: _________________________________

Body / whole

Work activities, such as:

Building maintenance
Construction
Logging
Utility work
Other: _________________________________

Work-related exposure to:

Working from heights of four feet or more
Working near water
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Fall arrest/restraint:
- Type: _______________________________
PFD:
- Type: _______________________________

Lungs / respiratory

Work activities, such as:

Cleaning
Pouring
Mixing
Sawing
Painting
Fiberglass installation
Compressed air or gas operations
Other: _________________________________

Work-related exposure to:

Irritating dust or particulate
Irritating or toxic gas/vapor
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Air Purifying Respirator
- Type: _______________________________
Supplied Air Respirator:
- Type: _______________________________

Refer to workplace respiratory protection program

*(See footnote 1)

Ears / hearing

Work activities, such as:

Generator
Grinding
Ventilation fans
Machining
Motors
Routers
Sanding
Sawing
Pneumatic equipment
Punch or brake presses
Use of conveyors
Other: _________________________________

Work-related exposure to:

Loud noises
Loud work environment
Noisy machines/tools
Punch or brake presses
Other: _________________________________

Can hazard be eliminated without the use of PPE?

If no, use:

Disposable Inserts with NRR of __________
Ear muffs with NRR of _________________
Other: ______________________________

Refer to workplace hearing protection program

*(See footnote 1)

(1) Note: There are other hazards requiring PPE (such as respiratory, noise, fall hazards), that require additional training and written programs.

Reference

Washington Department of Labor and Industry

To learn more about Hanover Risk Solutions, visit hanoverrisksolutions.com.

This material is provided for informational purposes only and does not provide any coverage or guarantee loss prevention.The examples in this material are provided as hypothetical and for illustration purposes only. 华体会 Insurance Company and its affiliates and subsidiaries (鈥溁寤徕€�) specifically disclaim any warranty or representation that acceptance of any recommendations contained herein will make any premises, or operation safe or in compliance with any law or regulation. By providing this information to you, 华体会 does not assume (and specifically disclaims) any duty, undertaking or responsibility to you. The decision to accept or implement any recommendation(s) or advice contained in this material must be made by you.