Hazard Assessment Form

Instructions

Print this form and use it as a guide for your walk-through survey. It will help you identify the hazards in each work area. Once you've completed the Hazard Assessment, review the Guidelines for Selecting Personal Protective Equipment.

Head Hazards

Tasks that can cause head hazards include: Working below other workers who are using tools and materials which could fall, working on energized electrical equipment, working with chemicals and working under machinery or processes which might cause materials or objects to fall.

Check the appropriate box for each hazard:

				Description of hazards:
	Burn	Yes	No
	Chemical Splash	Yes	No
	Electrical Shock	Yes	No
	Impact	Yes	No

Eye & Face Hazards

Tasks that can cause eye or face hazards include: Working with acids and chemicals, chipping, grinding, furnace operations, sanding, welding and woodworking.

Check the appropriate box for each hazard:

				Description of hazards:
	Chemicals	Yes	No
	Dust	Yes	No
	Heat	Yes	No
	Impact	Yes	No
	Light/Radiation	Yes	No
	Grinding	Yes	No

Respiratory Hazards

Respirators should not be the first choice for respiratory protection in the workplace. They should only be used when engineering or administrative controls are not technically feasible, while engineering controls are being installed and/or repaired or when emergencies or other temporary situations arise.

Check the appropriate box for each hazard:

				Description of hazards:
	Toxic Gases or Vapors	Yes	No
	Chemicals	Yes	No
	Dust or Particulate	Yes	No
	Fumes	Yes	No
	Oxygen Deficiency	Yes	No
	Other	Yes	No

Hearing Hazards

Tasks that can cause hearing hazards include: Working with or around loud machinery or tools.

Check the appropriate box for each hazard:

				Description of hazards:
	Loud Noise	Yes	No
	Impact Noise	Yes	No
	Loud Machinery	Yes	No
	Other	Yes	No

Hand Hazards

Tasks that can cause hand hazards include: Cutting material, working with chemicals and working with hot objects.

Check the appropriate box for each hazard:

				Description of hazards:
	Burns	Yes	No
	Chemical Exposure	Yes	No
	Cuts/Abrasion	Yes	No
	Puncture	Yes	No

Foot Hazards

Tasks that can cause foot hazards include: Carrying or handling materials that could be dropped, performing manual material handling and working with chemicals.

Check the appropriate box for each hazard:

				Description of hazards:
	Chemical Exposure	Yes	No
	Compression	Yes	No
	Impact	Yes	No
	Puncture	Yes	No

Other Required PPE

Do hazards exist that require PPE for the Body? Chemical splash hazards, electrical arc hazards and bloodborne pathogens are some examples of hazards that can affect the body and may require PPE to protect clothing and skin from harm or contamination.

Check the appropriate box for each hazard:

				Description of hazards:
	Chemical	Yes	No
	Heat/Arc	Yes	No
	Hazardous Particulate ie. asbestos/lead	Yes	No
	Non-Hazardous Particulate	Yes	No

Guidelines for Selecting Personal Protective Equipment (PPE)

Note: Personal Protective Equipment alone should not be relied on to provide protection against hazards, but should be used in conjunction with guards, engineering controls and sound manufacturing practices.

1. Familiarize yourself with the potential hazards in the area and the types of PPE that are available.
2. Consider the hazards associated with the environment (impact velocities, masses, projectable shape, radiation intensities, etc.).
3. Select PPE that ensures a greater level of protection than the minimum required to protect workers from the hazards.
4. Fit the worker with the PPE and give instructions on its use and care. It is very important that workers be made aware of all warning labels for and limitations of their PPE.

Based on the hazard assessment for ______________________________ (Job Classification), the following PPE is required:

(rev. 3/11)