Personal Protective Equipment (PPE) Hazard Assessment Survey and

Analysis
Department:                     _____                                               Location:                                                                              

Job Position:            ___                                  Operation/Process:                                                                                 

Person Performing Assessment:                                   ____                          Title:                                                       

The Following Hazards Have Been Noted

HANDS ✔ HAZARD ✔ REQUIRED PPE
Penetration - Sharp Objects Leather/Cut Resistant Gloves
Penetration - Animal Bites Leather/Cut Resistant Gloves
Penetration - Rough Objects General Purpose Work Gloves
Chemical(s)_________________________________________ Chemical Resistant Gloves (Dependent on chemical hazard)
Extreme Cold Insulated Gloves
Extreme Heat Heat/Flame Resistant Gloves
Blood Latex or Nitrile Gloves
Electrical Shock Insulated Rubber Gloves
Vibration-Power Tools Cotton, Leather, or Anti-Vibration Gloves
Other______________________________________________ Other______________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
FACE AND EYES ✔ HAZARD ✔ REQUIRED PPE
Exposure to Sparks Leather Welding Hood
Safety Glasses w/ Side Shields
Impact-Flying Objects, Chips, Sand, Dirt
Safety Glasses/Goggles w/ Face Shield
Nuisance Dust Impact Goggles
Welding goggles
UW light-welding, cutting, torch brazing, or soldering
Welding helmet/shield w/safety glasses and side shields
Chemical - Splashing Liquid Chemical Goggles/ Face Shield
Chemical - Irritating Mists Chemical Splash Goggles
Hot Sparks - Grinding Safety Glasses w/ Side Shields / Face Shield
Splashing Molten Metal Safety Goggles / Face Shield
Sun Exposure/Glare/High Intensity Lights Shaded Safety Glasses
Laser Operations Laser Safety Glasses/Goggles (WV specific)
Other______________________________________________ Other______________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
EARS ✔ HAZARD ✔ REQUIRED PPE

Exposure to noise levels (85 dBA 8-hour TWA) Ear Muffs or Plugs

RESPIRATORY SYSTEM ✔ HAZARD ✔ REQUIRED PPE

Nuisance Dust/Mist Disposable Dust/Mist Mask
Welding Fumes Welding Respirator
Asbestos Respirator w/HEPA Filter
Pesticides Respirator w/Pesticide Cartridge
Isocyanates Air Supplied Respirator
Paint Spray Respirator w/Paint Spray Cartridge
Organic Vapors Respirator w/ Organic Cartridge
Acid Gases Respiratore w/Acid Gas Cartridge
Oxygen Deficient/ Toxic/ or IDLH Atmosphere SCBA or Type C Airline Respirator
Other______________________________________________ Other______________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________

Rev 03/24/2022 1 of 2
 FOOT ✔ HAZARD ✔ REQUIRED PPE
Impact-Heavy Objects Steel Toe Safety Shoes
Compression-Rolling or Pinching Objects/Vehicles Leather Boots or Safety Shoes w/Metatarsal Guards
Slippery or Wet Surface Slip Resistant Shoes
Penetration-Sharp Objects Puncture Resistant Shoes
Penetration-Chemicals Chemical Resistant Boots/Covers
Exposure to Extreme Cold Insulated Boots or Shoes
Other______________________________________________ Other______________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
HEAD ✔ HAZARD ✔ REQUIRED PPE
Struck By Hard Hat
Top of Head Only Type 1
Lateral or Top of Head Hazard Type 2
Electrical-Contact with Exposed Wires/Conductors Electrical Class
Other______________________________________________ Other______________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
BODY ✔ HAZARD ✔ REQUIRED PPE
Impact-Flying Objects Long Sleeves/Apron/Coat
Moving Vehicles High Visibility Vest
Penetration-Sharp Objects Cut-Resistant Sleeves/Wristlets
Electrical-Static Discharge Static Control Coats/Overalls
Hot Metal/Sparks Flame-Resistant Jacket/Pants
Chemical(s)_________________________________________ Lab Coat or Apron/Sleeves
Exposure to Extreme Cold Insulated Jacket/Hood/Pants
Exposure to Extreme Heat Body Cooling Devices
Unprotected Elevated Walking/Working Surface Body Harness/Lanyard
Other______________________________________________ Other______________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________

CERTIFICATION: I certify that I personally performed the above Hazard Assessment on the date indicated.
This document is a Certification of the Hazard Assessment .

Signed by:                   __________                                                                   Date:     _____                                

Rev 03/24/2022 2 of 2