PPE hazard assessment and certification

Use this sample form to identify hazards and to certify (document in writing) that you completed the assessment.
Keep it on file in your workplace.

Survey your workplace as often as necessary to identify safety and health hazards that require personal protective
equipment.

General information
Department: Click here to enter text Location: enter text
Jobs included in the assessment: enter text
Person performing assessment: enter text
Assessment date: pick date

Hazard assessment certification

I certify that I performed this hazard assessment on the date indicated.

Signed:____________________________________________________________ Date: pick date

Type name here

PPE Required?
From the attached assessment worksheets Yes No
Fall protection
Torso protection
Eye and face protection
Head protection
Foot protection
Leg protection
Hand protection
Hearing protection
Respiratory protection

Page 1 | General information

PPE hazard assessment and certification
Fall protection
All employees performing construction work must be protected from fall hazards when working on unguarded
surfaces 6 feet or more above a lower level or at any height above dangerous equipment.
Fall protection systems must be provided, installed, and used according to the criteria in 1926.502(d), and 437-003-
0502 in Division 3/M, Construction/Fall Protection.

All employees performing general industry work must be protected from fall hazards when working on unguarded
surfaces 4 feet or more above a lower level or at any height above dangerous equipment.
Fall protection systems must be provided, installed, and used according to the criteria in 1910.28, and 1910.29 in
Division 2/D, General Industry/Walking-Working Surfaces.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Unguarded surfaces more than 6 or 4 feet above a lower level or any height above dangerous
equipment

Likelihood of injury without PPE

High
Medium
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe - life threatening

PPE required
Personal fall arrest system
Personal fall restraint system
None required

Page 2 | Fall protection

PPE hazard assessment and certification
Torso protection
Clothing that is appropriate to the work performed and conditions encountered must be worn.
Appropriate high temperature protective clothing must be worn by workers who are exposed to molten metals or
other substances that can cause burns.
Loose sleeves, ties, lapels, cuffs, or other loose clothing must not be worn near moving machinery.
Clothing saturated or impregnated with flammable liquids, corrosive or toxic substances, irritants, or oxidizing
agents must be removed immediately and not worn again until properly cleaned.
Rings, wristwatches, earrings, bracelets, and other jewelry that might contact power driven machinery or electric
circuitry must not be worn.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Extreme temperatures PPE required
Chemical resistant coveralls
Hot splashes from molten metal and other
hot liquids Cut-resistant sleeves, wristlets
Impacts from tools, machinery, and Flame-resistant jacket/ pants
materials High visibility garment
Hazardous chemicals Insulated jacket, hood
Ionizing radiation Lab coat or apron/ sleeves
Likelihood of injury without PPE Long sleeves/ apron/ coat
High Static control coats/ coveralls
Medium None required
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe - life threatening

Page 3 | Torso protection

PPE hazard assessment and certification
Eye and face protection
Employees must use appropriate eye or face protection when exposed to flying particles, molten metal, liquid
chemicals, acids or caustic liquids, chemical gases or vapors, or potentially injurious light radiation.
Eye protection must have side protection when there is a hazard from flying objects. Detachable side protectors
meeting ANSI Z87.1 requirements are acceptable.
Employees who wear prescription lenses must wear eye protection that fits over the lenses without disturbing the
proper position of the prescription lenses, or ANSI-approved prescription lenses with side shields.
Employees who are exposed to potentially injurious light radiation must use filter lenses that have a shade number
appropriate for the work being performed.
Employees whose work exposes them to laser beams must wear laser safety goggles that protect for the wavelength
of the laser.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards Chemical splash goggles

Dust, dirt, metal, or wood chips from Glasses/goggles w/face shield
chipping, grinding, sawing, hammering,
and from power tools Glasses/goggles w/face shield
Chemical splashes from corrosive Impact goggles
substances, hot liquids, and solvents Leather welding hood
Objects such as tree limbs, chains, tools, Safety glasses w/side shields
and ropes that swing into the eyes or face Safety goggles w/face shield
Radiant energy from welding and harmful Welding goggles
rays from lasers or other radiant light
Welding helmet/shield w/safety glasses
Likelihood of injury without PPE and side shields
High None required
Medium
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe – life threatening

PPE required
Chemical goggles/face shield

Page 4 | Eye and face protection

PPE hazard assessment and certification
Head protection
Employees must wear hardhats when they work where there is a potential for head injuries from falling or flying
objects.
Employees must use hard hats designed to reduce electrical shock hazards when they’re working near exposed
electrical conductors that could contact their heads.
Employees who are exposed to power-driven machinery or to sources of ignition must wear caps or other head
covering that completely covers their hair.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Overhead objects that could fall PPE required:
Head protection that meets ANSI Z89.1
Exposed pipes or beams (less than 6.5 feet
requirements:
overhead)
Energized electrical equipment Impact Type I
Impact Type II
Likelihood of injury without PPE
Electrical Class G (general)
High
Electrical Class E (electrical)
Medium
Electrical Class C (conductive)
Low
None required
Severity of a potential injury without PPE
Minor first aid required
Serious, not life threatening
Severe – life threatening

Page 5 | Head protection

PPE hazard assessment and certification
Foot protection
Employees must wear protective footwear when they work where there is a danger of foot injuries due to falling or
rolling objects, or objects piercing the sole, or electrical hazards.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Heavy objects such as barrels or tools that PPE required
might roll onto or fall on a worker’s feet Steel toe safety shoes
Sharp objects such as nails or spikes that Leather boots or safety shoes w/metatarsal
could pierce the soles or uppers of guards
ordinary shoes Slip resistant soles
Molten metal Puncture resistant soles
Hot, wet, or slippery surfaces Chemical resistant boots/covers
Energized electrical equipment Rubber boots/closed top shoes
Likelihood of injury without PPE Insulated boots or shoes
High None required
Medium
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe – life threatening

Page 6 | Foot protection

PPE hazard assessment and certification
Leg protection
Workers exposed to hot substances or dangerous chemical spills must wear leggings or high boots made of leather,
rubber, or other suitable material.
Workers who use chain saws must wear chaps or leg protectors that cover the leg from the upper thigh to mid-calf.
Leg protectors must be made from material that resists cuts from the chain saw.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Hot substances
Dangerous chemicals
Cuts from chain saws

Likelihood of injury without PPE

High
Medium
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe – life threatening

PPE required
Leggings or boots – penetration resistant
Leggings or boots – chemical resistant
Leggings or boots – molten metal resistant
Chaps or leg protectors – resists cuts from chain saws
None required

Page 7 | Leg protection

PPE hazard assessment and certification
Hand protection
Employees must use appropriate hand protection when their hands are exposed to harmful substances, severe cuts or
lacerations, abrasions, punctures, chemical burns, thermal burns, and extreme temperatures.
Employers must base the selection of the appropriate hand protection on an evaluation of the performance
characteristics of the hand protection relative to the task, conditions present, duration of use, and the hazards
identified.
Employees must not wear gloves when their hands could be caught in moving parts.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Harmful or hazardous temperatures PPE required
Leather/cut resistant gloves
Chemicals that can be absorbed into the
skin or cause burns General-purpose work gloves
Energized electrical equipment Chemical resistant gloves
Mechanical equipment that can cause Insulated gloves
bruises, abrasions, cuts, punctures, Heat/flame resistant gloves
fractures, or amputations
Latex or nitrile gloves
Likelihood of injury without PPE Electrician’s insulated rubber gloves;
High Cotton, leather, or anti-vibration gloves
Medium None required
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe – life threatening

Page 8 | Hand protection

PPE hazard assessment and certification
Hearing protection
Hearing protectors (plugs or muffs) must be worn by workers exposed to an 8-hour time-weighted average of 85
decibels or greater and by workers who have experienced a threshold shift.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: enter text

Potential hazards
Noise levels that exceed those shown in the table below are hazardous:
Hours of exposure Sound level (dBA)
8.0 90
6.0 92
4.0 95
3.0 97
2.0 100
1.5 102
1.0 105
0.5 110
0.25 115

Likelihood of injury without PPE

High
Medium
Low

Severity of a potential injury without PPE

Minor first aid required
Serious, not life threatening
Severe – life threatening

PPE required
Ear plugs
Ear muffs
None required

Page 9 | Hearing protection

PPE hazard assessment and certification
Respiratory protection
Appropriate respirators are required when workers are exposed above permissible exposure limits (PEL) for specific
air contaminates, listed in 437-002-0382, Oregon Rules for Air Contaminants; see also 1910.134, Respiratory
Protection.

Department: Click here to enter text Location: enter text

Jobs included in the assessment: to enter text

Potential hazards
Nuisance dust/mist PPE required
Air-purifying respirators
Welding fumes
Filtering face piece (dust mask)
Asbestos
Particulate-removing respirator
Pesticides
Gas-and-vapor-removing respirator
Isocyanates
Combination aerosol filter/gas or vapor-
Paint spray
removing respirator
Organic vapors
Powered air-purifying respirator
Acid gases
Atmosphere-supplying respirators
Oxygen deficient/ toxic or IDLH
Supplied-air respirator
atmosphere
Self-contained breathing apparatus
Likelihood of injury without PPE (SCBA)
High Combination self-contained breathing
Medium apparatus and air-line respirator
Low Combination air-purifying and
atmosphere-supplying respirators
Severity of a potential injury without PPE None required
Minor first aid required
Serious, not life threatening
Severe – life threatening

Page 10 | Respiratory protection