CHECKLIST – PPE ASSESSMENT
Suggested Questions Typical Operations of Yes No
Concern
EYES
Do your employees perform tasks, or Sawing, cutting, drilling, sanding, X
work near employees who perform grinding, hammering, chopping,
tasks, that might produce airborne abrasive blasting, etc.
dust or flying particles?
Do your employees handle, or work Pouring, mixing, painting, cleaning, X
near employees who handle, spraying, dispensing, and providing
hazardous liquid chemicals or first aid, etc.
encounter blood splashes?
Are your employees’ eyes exposed to Battery charging, installing fiberglass X
other potential physical or chemical insulation, compressed air or gas
hazards? operations, etc.
Are your employees exposed to Welding, cutting, etc. X
intense light?
FACE
Do your employees handle, or work Pouring, mixing, painting, cleaning, X
near employees who handle, providing first aid, etc.
hazardous liquid chemicals?
Are your employees’ faces exposed Welding, baking, cooking, drying, etc. X
to extreme heat?
Are your employees faces exposed Cutting, sanding, grinding, X
to other potential hazards? hammering, chopping, pouring,
mixing, painting, cleaning, dispensing,
etc.
HEAD
Could tools, tree limbs or other Work stations or traffic routes located X
objects fall from above and strike under catwalks, open sided floors,
your employees on the head? construction, trenching, utility work,
tree trimming, etc.
Are your employees’ heads near Construction, confined space X
exposed beams, machine parts, operations, building maintenance, etc.
pipes, etc. when they stand or bend,?
Do your employees work with or near Building maintenance; construction; X
exposed electrical wiring or wiring; work on or near
components? communications, computer, or other
high tech equipment; arc or
resistance welding; etc.
CHECKLIST – PPE ASSESSMENT
Suggested Questions Typical Operations of Yes No
Concern
FEET
Could tools, heavy equipment, or Construction, plumbing, building X
other objects roll, fall onto, or strike maintenance, trenching, grass cutting,
your employees’ feet? etc.
Are your employees subject to Construction, machine shop X
walking on sharp objects? operations, building maintenance,
utility work, material handling, etc.
Do your employees work with or near Building maintenance; construction; X
exposed electrical wiring or wiring; work on or near
components? communications, computer, or other
high tech equipment; arc or
resistance welding; etc.
Do your employees handle, or work Welding, etc. X
near employees who handle, molten
metal?
Do your employees work with Spray painting, abrasive blasting, work X
explosives or in explosive with highly flammable materials,
atmospheres? etc.
HANDS
Do your employees handle chemicals Pouring, mixing, painting, cleaning, X
that might irritate or damage skin, or providing first aid, etc.
come into contact with blood?
Do work procedures require your Welding, baking, cooking, drying, etc. X
employees to place their hands and
arms near extreme heat?
Are your employees’ hands and arms Building maintenance; construction; X
placed near exposed electrical wiring wiring; work on or near
or components? communications, computer, or other
high tech equipment; arc or
resistance welding; etc.
CHECKLIST – PPE ASSESSMENT
Suggested Questions Typical Operations of Yes No
Concern
BODY
Are your employees’ bodies exposed Pouring, mixing, painting, cleaning, X
to irritating dust or hazardous machining, sawing, battery charging,
chemical splashes, such as acids? installing fiberglass insulation,
compressed air or gas operations,
etc.
Are your employees’ bodies exposed Cutting, grinding, sanding, sawing, X
to sharp or rough surfaces? glazing, material handling, etc.
Are your employees’ bodies exposed Welding, baking, cooking, drying, etc. X
to extreme heat?
HEARING
Are your employees’ bodies exposed Machining, grinding, sanding, work X
to loud noise from machines, tools, near pneumatic equipment,
music systems, etc? generators, ventilation fans, motors,
brake presses, chainsaws, etc.
Form
Certification of Hazard Assessment for
PERSONAL PROTECTIVE EQUIPMENT
School Assessed: ________________________________________________
Department Assessed: ____________________________________________
Assessment Date: ________________________________________________
Person Completing Assessment: _____________________________________
Gather, List, and Review Documentation. Include the following:
Operating Procedures
Workplace Practices
Safety Procedures
Material Safety Data Sheets
Other Pertinent Information
________________________________________________________________
________________________________________________________________
Walk through area being assessed.
In the documentation review and walk through, focus on the following:
Motion hazards
Impact
Penetration (sharp objects)
Compression (roll over)
Falling (or potentially falling) objects
Rolling or pinching objects
Chemical exposures
High (or low) temperatures (include possible effects of high
stress)
Harmful dust
Light (optical) radiation
Workplace layout
Location of co-workers
Electrical hazards
Data Analysis
Estimate of potential for injuries
Type of risk(s)
Level of risk(s)
Severity of potential injury
Potential of simultaneous exposure to several hazards
PPE Selected
Area Process
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
This document certifies that a hazard assessment for the selection of personal
protective equipment pursuant to 29 CFR 1910.132(d) was conducted.
Assessor Signature: ____________________________ Date: ___/___/___
Form
Certification of Training and Understanding
on
PERSONAL PROTECTIVE EQUIPMENT
School: _____________________________________________
Department: _________________________________________
PPE Types:
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
Training:
When PPE is necessary
What PPE is necessary
How To properly inspect PPE for wear or damage
How to properly put on, take off, adjust the fit, and wear PPE
The limitations of PPE
The proper care, maintenance, useful life and disposal of
PPE
Each employee must demonstrate an understanding of the training
and the ability to use the PPE properly.
Written certification for each affected employee.
This document certifies that the employees listed below have
received and demonstrated their understanding of the training in the
personal protective equipment necessary for their jobs pursuant to 29
CFR 1910.132 (f).
Employees Trained Date(s) of Training
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
Trainer:
Signature Printed Name
Date: ___/___/___
