Checklists : Personal Protective Equipment Hazard Review Forms

PERSONAL PROTECTIVE EQUIPMENT HAZARD REVIEW FORMS

Instructions: You can use the following charts and tables to complete a hazard assessment of your worksite. Using them will give you a basis for determining if personal protective equipment is necessary and what type of equipment to use. It is not fool proof, but it does take some of the guesswork out of the decision-making process.


Col # Chart/Table Action
1&2

Personal Protective Equipment Review

Using this Chart, review the first column on the list (Eye & Face Protection). If employees are exposed to any item listed under that heading, enter "Yes" in Column 2.

If the answer is "No", skip this section. Go to the second item on the list (Head Protection). When you enter a "Yes" in Column 2, go to next step.

3 Comment

Use this column to enter information you may need, such as the name of the job or job task that exposes the employee to a hazard.

4 Source of Hazard

Enter the source of the hazard, i.e., flying particles, slashing acid, as an aid to you're decision making process.

5 Hazard Frequency Enter how long the job or task lasts - 8 hours, 4 hours, continuous - in order to determine how long the employee is exposed to the hazard.
6 Hazard Probability A,B,C,D

Using the Hazard Probability & Severity Chart (next page), enter the alpha character (A, B, C, D) that explains the likelihood of an accident occurring.

A - Likely to occur immediately or within a short period of time
B - Probably will occur in time
C - May occur in time
D - Unlikely to occur

7 Hazard Severity

Using the Hazard Probability & Severity Chart (next page), enter the alpha character (C, M, N) that explains how severe the injury would be if it did occur.

CRITICAL - May cause severe injury
MARGINAL - May cause minor injury
NEGLIGIBLE - Probably would not affect personnel or may cause first aid visit

8 Hazard Index 1-2-3

Using the Hazard Probability & Severity Chart (next page), find where the alpha characters intersect in the Index and enter the numeric character (1-2-3).

1. PPE is required
2. PPE is strongly recommended
3. PPE may not be necessary

9 Appropriate PPE Enter in type of PPE that will be provided and used to protect the employee from the hazard if Hazard Index is 1 or 2. The employer must determine whether or not PPE is to be used.

 

PERSONAL PROTECTIVE EQUIPMENT
HAZARD REVIEW CHARTS & TABLE

Hazard Index Table
In all cases, engineering modifications are strongly recommended. Personal protective equipment (PPE) cannot be used in lieu of feasible engineering controls
1. PPE is required. 2. PPE is strongly recommended. 3. PPE may not be necessary.

 

PPE Matrix Hazard Severity
Hazard Probability CRITICAL
May cause severe injury (C) 		MARGINAL
May cause minor injury (M) 		NEGLIGIBLE
Probably would not affect personnel or may cause first aid visit (N)
A - Likely to occur immediately or within a short period of time 1 1 2
B - Probably will occur in time 1 2 2
C - May occur in time 2 2 3
D - Unlikely to occur 2 3 3

PERSONAL PROTECTIVE EQUIPMENT REVIEW

Part 1 of 2
1 ITEM 		2
Yes/No 		3
Comments (Job) 		4
Source of Hazard		 5
Frequency of Exposure (HRS)
FOOT PROTECTION        
The employee handles heavy material or works in an area where there is potential exposure to foot injury due to falling or rolling objects        
The employee works in an area where there is potential exposure to foot injury due to an object piercing the sole of the shoe from sharp edges or points        
Employees are working in an area where floor surfaces are such that they may create a slip hazard.        
Employees are working in an area where there are molten metals        
Employees are working in an area where there are exposed electrical wires.        
Employees work in an area with wet conditions        
Employees work in construction or demolition areas        

Part 2 of 2
1 ITEM 		6
Hazard Probability A-B-C-D 		7
Hazard Severity C-M-N 		8
Hazard Index 1-2-3 		9
Appropriate PPE
FOOT PROTECTION        
The employee handles heavy material or works in an area where there is potential exposure to foot injury due to falling or rolling objects        
The employee works in an area where there is potential exposure to foot injury due to an object piercing the sole of the shoe from sharp edges or points        
Employees are working in an area where floor surfaces are such that they may create a slip hazard.        
Employees are working in an area where there are molten metals        
Employees are working in an area where there are exposed electrical wires.        
Employees work in an area with wet conditions        
Employees work in construction or demolition areas        

Part 1 of 2
1 ITEM 		2
Yes/No 		3
Comments (Job) 		4
Source of Hazard		 5
Frequency of Exposure (HRS)
HAND PROTECTION        
The employee's hands are exposed to chemicals that might irritate the skin        
The employee's hands are exposed to bacteriological agents, blood or other infectious materials        
The employee's hands are exposed to extreme vibration from working with vibrating tools        
The employee's hands are exposed to sharp tools or machine parts (cuts, lacerations, abrasions)        
The employee's hands are exposed to electrical wires        
The employee works in material handling activities (cuts, abrasions)        
The employee's hands are exposed to sharp edges or splinters (puncture wounds)        

Part 2 of 2
1 ITEM 		6
Hazard Probability A-B-C-D 		7
Hazard Severity C-M-N 		8
Hazard Index 1-2-3 		9
Appropriate PPE
HAND PROTECTION        
The employee's hands are exposed to chemicals that might irritate the skin        
The employee's hands are exposed to bacteriological agents, blood or other infectious materials        
The employee's hands are exposed to extreme vibration from working with vibrating tools        
The employee's hands are exposed to sharp tools or machine parts (cuts, lacerations, abrasions)        
The employee's hands are exposed to electrical wires        
The employee works in material handling activities (cuts, abrasions)        
The employee's hands are exposed to sharp edges or splinters (puncture wounds)        

Part 1 of 2
1 ITEM		 2
Yes/No 		3
Comments (Job) 		4
Source of Hazard		 5
Frequency of Exposure (HRS)
EYE & FACE PROTECTION Employees are exposed to flying particles, molten metal, liquid chemicals, acids, caustic liquids, chemical gases or vapors, or potentially harmful light radiation.        

HEAD PROTECTION

-The employee works in an area where there is a potential for injury to the head from a falling object.
- The employee works in an area near exposed electrical conductors which could contact the head.
- The employee works in an area where a "caught on" hazard exists for hair.

       
FALL PROTECTION Employees are working at an elevated work area where a slip or fall to a lower level is a potential hazard.        
CLOTHING PROTECTION Employees are exposed to harmful materials, chemicals, temperature extremes, or source of cuts, lacerations or punctures.        
HEARING PROTECTION Employees are exposed to sound levels in excess of 85dBA on an 8-hour TWA        
RESPIRATORY PROTECTION Employees are exposed to air contaminates such as dust, mist or fume. Air monitoring has indicated overexposure.        

Part 2 of 2
1 ITEM		 6
Hazard Probability A-B-C-D 		7
Hazard Severity C-M-N 		8
Hazard Index 1-2-3 		9
Appropriate PPE
EYE & FACE PROTECTION Employees are exposed to flying particles, molten metal, liquid chemicals, acids, caustic liquids, chemical gases or vapors, or potentially harmful light radiation.        

HEAD PROTECTION

-The employee works in an area where there is a potential for injury to the head from a falling object.
- The employee works in an area near exposed electrical conductors which could contact the head.
- The employee works in an area where a "caught on" hazard exists for hair.

       
FALL PROTECTION Employees are working at an elevated work area where a slip or fall to a lower level is a potential hazard.        
CLOTHING PROTECTION Employees are exposed to harmful materials, chemicals, temperature extremes, or source of cuts, lacerations or punctures.        
HEARING PROTECTION Employees are exposed to sound levels in excess of 85dBA on an 8-hour TWA        
RESPIRATORY PROTECTION Employees are exposed to air contaminates such as dust, mist or fume. Air monitoring has indicated overexposure.