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CERTIFICATION OF HAZARD ASSESSMENT AND

PERSONAL PROTECTIVE EQUIPMENT SELECTION WORKSHEET


All sections must be completed.
Date of Assessment

Name(s) of Evaluators Job Title of Evaluator(s)

Description of Worksite Location or Employees to Which Hazard Assessment Applies

Head Protection

The heads of employees at this worksite have a


reasonable potential of coming into contact with: If yes, then select

Overhead low voltage conductors to 2,200 volts and


impact and penetration hazards Class A Helmets
Yes No

Overhead high voltage conductors to 20,000 volts and


impact and penetration hazards Class B Helmets
Yes No

Impact and Penetration Hazards Only:


(e.g. moving machinery, falling or flying Class C Helmets
objects, and/or protruding, stationary objects.
Yes No

Hand Protection

The hands of employees at this worksite have a


reasonable potential of coming into contact with:
Temperature extremes of heat or cold Yes No
Liquid chemicals (e.g. solvents, corrosives) Yes No
Electrical hazards Yes No
Hand tools used on a regular basis Yes No
Machinery or other equipment with the
potential to cut or abrade the user Yes No
Blood or other body fluids Yes No

If you answered yes to any of the above, specify the hand protective equipment selected per the guidelines in
the Injury and Illness Prevention Program and Section 4 of the Safety Coordinator's Manual.

Distribution: Department Safety Coordinator


Eye/Face Protection

The eyes and/or face of employees at this worksite have a


reasonable potential of coming into contact with: If yes, then select

IMPACT HAZARDS-- Chipping, grinding, machining, Spectacles with side protection


masonry, wood-working, sawing, drilling, chiseling, or goggles. For severe exposure, use
powered fastening, riveting, and sanding face shield. See notes 1, 3, 5, 6,10.
Yes No

HEAT HAZARDS-- Furnace operations, Goggles, or spectacles with


pouring, casting, hot dipping and welding. side protection. For severe exposure, use
Yes No faceshield. See notes 1,2,3.

Splash from molten metals Faceshields worn over goggles.


Yes No See notes 1,2,3.

High temperature exposure Reflective face shield. See notes 1,2,3.


Yes No

CHEMICAL HAZARDS-- Acid and chemicals Indirectly vented goggles. For severe
handling, degreasing and plating exposure, use face shield. See notes 3, 11.
Yes No

Irritating mists Indirectly vented or non-vented


Yes No goggles. For severe exposure, use face shield.

DUST -- Woodworking, buffing, general dusty Goggles. See note 8.


conditions. Yes No

LIGHT and/or RADIATION

General Electrical Work Spectacles with polycarbonated lenses which


Yes No protect against radiation with wavelengths
of 200-400 nanometers (ultra-violet), 430-
440 nanometers (blue light), 770-1440
nanometers (infrared radiation), and 1400-
2000 nanometers.

Welding: Electric Arc Welding helmets or welding shields. Typical


Yes No shades: 10-14. See notes 9, 12.

Welding: Gas Welding goggles or welding face shield.


Yes No Typical shades: gas welding 4-8, cutting 3-6,
brazing 3-4. See note 9

Cutting, Torch brazing, Torch soldering Spectacles or welding faceshields: Typical


Yes No shades: 1.5-3. See notes 3, 9.

Glare Spectacles with shaded or special-purpose


Yes No lenses as suitable, e.g.. UV protective lenses
for outdoor work. See notes 9, 10.

Laser Spectacles with laser protective lenses. See


Yes No the Injury and Illness Prevention Program
or Section 4 of Safety Coordinators Manual.

BLOOD/BODY FLUIDS Spectacles with side protection.


Yes No
If you answered yes to any of the above, specify the eye/face protective equipment selected per the guidelines in this table and in the
Injury and Illness Prevention Program or Section 4 of the Safety Coordinator's Manual.
_________________________________________________________________________________________________________________________
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Notes to Eye and Face Protection Selection Table:


(1) Care should be taken to recognize the possibility of multiple and simultaneous exposure to a variety of hazards.
Adequate protection against the highest level of each of the hazards should be provided. Protective devices do not
provide unlimited protection.
(2) Operations involving heat may also involve light radiation. As required by the standard, protection from both
hazards must be provided.
(3) Faceshields should only be worn over primary eye protection (spectacles or goggles).
(4) As required by the standard, filter lenses must meet the requirements for shade designations in 29 CFR, §1910.133
(a)(5). Tinted and shaded lenses are not and shaded lenses are not filter lenses unless they are marked or identified as
such. See tables 4-2a and 4-2b below.
(5) As required by the standard, persons whose vision requires the use of prescription (Rx) lenses must wear either
protective devices fitted with prescription (Rx) lenses or protective devices designed to be worn over regular prescription
(Rx) eyewear.
(6) Wearers of contact lenses must also wear appropriate eye and face protection devices in a hazardous environment. It
should be recognized that dusty and/or chemical environments may represent an additional hazard to contact lens
wearers.
(7) Caution should be exercised in the use of metal frame protective devices in electrical hazard areas.
(8) Atmospheric conditions and the restricted ventilation of the protector can cause lenses to fog. Frequent cleansing may
be necessary.
(9) Welding helmets or faceshields should be used only over primary eye protection (spectacles or goggles).
(10) Non-sideshield spectacles are available for frontal protection only, but are not acceptable eye protection for the
sources and operations listed for "impact."
(11) Ventilation should be adequate, but well protected from splash entry. Eye and face protection should be designed
and used so that it provides both adequate ventilation and protects the wearer from splash entry.
(12) Protection from light radiation is directly related to filter lens density. See note (4). Select the darkest shade that
allow task performance.

Foot Protection

The feet of employees at this worksite have a


reasonable potential of coming into contact with:

Puncture hazards from sharp objects (e.g. nails, wire, staples) Yes No
Compression hazards such as from skid trucks, bulk rolls,
55-gallon drums, pipes or other objects which could potentially
roll over onto the feet. Yes No
Impact hazards resulting from carrying or handling materials
such as packages, objects, parts or heavy tools, which could be
dropped or other activities where objects might fall onto the
feet. Yes No
Electrical or electrostatic hazards Yes No
Chemical hazards such as from corrosive substances or hot tar Yes No
Temperature extremes such as from molten metal dripping onto
the feet or from walking through molten asphalt Yes No

Select safety footwear which is specifically designed to protect against the hazards specified above. The County's safety
footwear vendors can assist in the selection process. More detailed information on the selection process is provided in the
Injury and Illness Prevention Program and Section 4 of the Safety Coordinator's Manual.

Respiratory and Hearing Protection


Information on selecting respiratory and hearing protection are provided in the Injury and Illness Prevention Program
and Section 4 of the Safety Coordinator's manual. Selection of respiratory and hearing protection is to be performed by
the Department Safety Coordinator in conjunction with Occupational Safety and Environmental Compliance.

Signature of Evaluator(s) ____________________________________________________________

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