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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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?

• Yes
• No

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

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. The Hanover Insurance Company and its affiliates and subsidiaries (“The Hanover”) 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, The Hanover 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.