Appendix B
Hazard Assessment Certification Form
Date: | Location: |
Assessment Conducted By: |
|
Specific Tasks Performed at this Location: |
Hazard Assessment and Selection of Personal Protective Equipment
I. Overhead Hazards - Hazards to consider include:
- Suspended loads that could fall
- Overhead beams or loads that could be hit against
- Energized wires or equipment that could be hit against
- Employees work at elevated site who could drop objects on others below
- Sharp objects or corners at head level
Hazards Identified: |
Head Protection
Hard Hat: | Yes | No |
Types: Type A (impact and penetration resistance, plus low-voltage electrical insulation) Type B (impact and penetration resistance, plus high-voltage electrical insulation) Type C (impact and penetration resistance) |
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II. Eye and Face Hazards - Hazards to consider include:
- Chemical splashes
- Dust
- Smoke and fumes
- Welding operations
- Lasers/optical radiation
Hazards Identified: |
Eye Protection
Safety glasses or goggles | Yes | No |
Face shield | Yes | No |
III. Hand Hazards - Hazards to consider include:
- Chemicals
- Sharp edges, splinters, etc.
- Temperature extremes
- Biological agents
- Exposed electrical wires
- Sharp tools, machine parts, etc.
- Material handling
Hazards Identified: |
Hand Protection
Gloves | Yes | No |
Types: Chemical resistant Temperature resistant Abrasion resistant Other (Explain) |
IV. Foot Hazards - Hazards to consider include:
- Heavy materials handled by employees
- Sharp edges or points (puncture risk)
- Exposed electrical wires
- Unusually slippery conditions
- Wet conditions
- Construction/demolition
Hazards Identified: |
Foot Protection
Safety shoes | Yes | No |
Types: Toe protection Metatarsal protection Puncture resistant Electrical insulation Other (Explain) |
V. Other Identified Safety and/or Health Hazards:
Hazard | Recommended Protection |
I certify that the above inspection was performed to the best of my knowledge and ability, based on the hazards present on _______________________.
___________________________________________\ _________________________________
Signature Name