PPE HAZARD ASSESSMENT CERTIFICATION

EHS006.1
Date of Assessment:
Name of Work Place: Assessment Conducted by:
Work Area: Job/Task:
Assessment Certified By:

EY ES
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated without the use of PPE?
 Abrasive blasting  Sanding  Airborne Dust  Yes  No
 Chopping  Sawing  Flying Particles
 Cutting  Grinding  Blood Splashes If No, use
 Drilling  Hammering  Hazardous Liquid Chemicals  Safety Glasses  Side Shields Required
 Welding  Chemical Handling  Intense Light  Chemical Goggles
 Punch Press operations  Other:  Dust-tight Goggles
 Other:  Welding Shield  Shading/Filter #
 Other:
FACE
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated without the use of PPE?
 Cleaning  Foundry Work  Hazardous Liquid Chemicals  Yes  No
 Cooking  Welding  Extreme Heat/Cold
 Siphoning  Mixing  Potential Irritants: If No, use
 Painting  Chemical Handling  Other:  Face Shield
 Dip Tank Operations  Welding Shield  Shading/Filter #
 Other  Other:
HEAD
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated without the use of PPE?
 Building maintenance  Beams  Yes  No
 Confined space operations  Pipes
 Construction  Exposed electrical wiring or components If No, use
 Electrical wiring  Falling objects  Protective Helmet
 Walking/Working under catwalks  Machine parts  Class G (low voltage)
 Walking/Working under conveyor belts  Other:  Class E (high voltage)
 Walking/Working under loads being lifted  Class C
 Utility Work  Bump Cap (not ANSI approved)
 Other:  Hair Net or Soft Cap

Retention: Date+7yr PPE Hazard Assessment Certification Revision 1

 PPE HAZARD ASSESSMENT CERTIFICATION
EHS006.1
Date of Assessment:
Name of Work Place: Assessment Conducted by:
Work Area: Job/Task:
Assessment Certified By:

HANDS/ARMS
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated
 Sanding  Working with Glass  Blood/Bodily Fluids without the use of PPE? Glove Selections
 Grinding  Using Knives  Irritating Chemicals  Yes  No  Chemical Resistant
 Welding  Tools/Materials that could cut, scrape or  Leak Resistant
 Sawing bruise If No, use  Temperature Resistant
 Hammering  Extreme Heat/Cold  Gloves   Abrasion/Cut Resistant
 Drilling  Other:  Protective Sleeves  Slip Resistant
 Using Computers  Impact/Anti-Vibration
FEET/LEGS
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated
 Building Maintenance  Trenching  Explosive Atmospheres without the use of PPE?
 Construction  Use of PIV  Explosives  Yes  No Shoe/Boot Options
 Demolition  Welding  Exposure to Electrical Wiring or Components  Toe Protection
 Food Processing  Material Handling  Heavy Equipment If No, use:  Electrical Protection
 Use of Flammable  Slippery Surfaces  Safety Shoes/Boots   Puncture Resistant
Materials  Tools  Leggings/Chaps  Metatarsal Protection
 Plumbing  Other:  Foot/Leg Guards  Chemical Resistant
 Other  Anti-Slip
B ODY/SKIN
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated
 Battery changing  Chemical splashes without the use of PPE?
 Dip tank operations  Extreme Heat/Cold  Yes  No
 Fiberglass Removal or Installation  Sharp or Rough Edges  Coveralls, Body Suit
 Irritating Chemicals  Electrical If No, use
 Vest/Jacket  Raingear
 Sawing/Cutting  Other:  Apron
 Electrical  Welding Leathers
 Abrasion/Cut Resistant  Other:
 Other
Chaps

Retention: Date+7yr PPE Hazard Assessment Certification Revision 1

 PPE HAZARD ASSESSMENT CERTIFICATION
EHS006.1
Date of Assessment:
Name of Work Place: Assessment Conducted by:
Work Area: Job/Task:
Assessment Certified By:

B ODY/WHOLE
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated
 Building Maintenance  Working from heights of 4 feet or more without the use of PPE?
 Construction  Working near water  Yes  No
 Utility Work  Working over rotating/moving equipment
 Working at Heights  Electric current If No, use
 Other:  Other:  Fall Arrest/Restraint Type:
 PFD Type:
 Arc Flash Suit

LUNGS/RESPIRATORY
Work Activities, such as Work-Related Exposure to: Can the hazard be eliminated
 Cleaning  Pouring  Irritating Dust or Particulate without the use of PPE?
 Mixing  Sawing  Irritating or Toxic Gas/Vapor  Yes  No NOTE: To use any respirator, a
 Painting  Grinding  Other: written program must be
implemented. Non-mandatory dust
 Fiberglass If No, use:
mask use requires employee
installation/removal  Dust mask completion of the Appendix D. Use
 Welding – Stainless  Negative-Pressure of other respirators requires written
 Compressed Air/Gas Respirator program, medical clearance, and fit
Operations  Powered Air Purifying testing annually.
Respirator
EAR/HEARING
Work Activities, such as  Grinding Work-Related Exposure to: Can the hazard be eliminated
 Use of Generator  Machining  Loud Noises without the use of PPE?
NOTE: To use hearing protection
 Ventilation Fans  Routers  Loud Work Environment  Yes  No daily, a written program must be
 Motors  Electrical  Noisy Machines/Tools implemented and hearing
 Sanding/Cutting  Other:  Punch or Brake Presses If No, use
surveillance are required. Hearing
 Use of Pneumatic  Arc Blast  Ear Plugs
protection shall be selected based
Equipment  Other:  Canal Caps on noise level (i.e. the higher the
 Use of Conveyors  Ear Muffs noise level, the higher NRR the
hearing protection should have.

Retention: Date+7yr PPE Hazard Assessment Certification Revision 1

 PPE HAZARD ASSESSMENT CERTIFICATION
EHS006.1
Date of Assessment:
Name of Work Place: Assessment Conducted by:
Work Area: Job/Task:
Assessment Certified By:

Instructions for completing the PPE Hazard Assessment Certification

This tool assists in identifying hazards associated with jobs/tasks that a Diversey employee may perform. The tool helps to identify appropriate PPE
to be used while performing the associated jobs/tasks.
1. Do a walk through survey of each work area and job/task. Put a check or X next to the activities performed in the first column and add
activities not listed.
2. Put a check or X next to the exposure(s) in the second column
3. Decide the best way to control the hazard. Engineering controls to eliminate or minimize the hazard are always preferable. Administrative
controls such as job rotation are next preferable. If the hazard cannot be eliminated or minimized to an acceptable level without using PPE,
indicate which type of PPE will be required to protect employees from the hazard. Put a check or X next to each PPE required for the task,
based on the hazards identified.
4. Be sure that the header is completed with all information listed.

Retention: Date+7yr PPE Hazard Assessment Certification Revision 1