The following form shall be used to assess the hazards to which an employee may be exposed to determine if there are hazards present in the environment which necessitate the use of personal protective equipment (PPE). It is the responsibility of Departments and Administrative Units to complete this paperwork for each work area and submit it to the Office of Environmental Health & Safety, TW16.

Name of Person Doing Assessment:_____________________________________________
Work Area (Campus, Building, Room #, Other):_________________________________
Date of Assessment:____________________________

Chemical or Infectious Hazards:
1. Are hazardous chemicals or infectious materials used in this work area?
___ Yes ___ No
2. What types of hazardous chemicals or materials are used? (Check all that apply)
___ Corrosives ___ Flammables ___ Toxics ___ Oxidizers ___ Biohazards
___ Carcinogens (Pease list)___________________________________
___ Explosives ___ Radioactive Materials ___ Infectious Agents
___ Other (Please list)________________________________________
3. What personal protective equipment is recommended for use with these materials (see Material Safety Data Sheets or other sources of information)? (Check all that apply)
___ Gloves ___ Chemical Apron ___ Respirator ___ Goggles
___ Lab coat ___ Safety Glasses ___ Face Shield ___ Shoe Covers
___ Other______________________________________

Harmful Dust:
4. Are there sources of harmful dust to which employees may be exposed (such as from blasting, buffing, woodworking, mixing of concrete and/or glazes for art, etc.) in this work area? ___ Yes ___ No
5. What personal protective equipment is recommended (see Material Safety Data Sheets or other sources of information)? (Check all that apply)
___ Gloves ___ Dust/Mist Respirator ___Safety Glasses ___Goggles
___ Face Shield ___ Other___________________________________

6. Are there activities in which employees may encounter compression hazards such as from hydraulic jacks, tools, presses, or compactors in this work area? ___ Yes ___ No
7. Are forklifts used in this work area? ___ Yes ___ No
8. Do employees install or work with heavy pipes in this work area?
___ Yes ___ No
9. Are there objects in the work area which may roll over an employee's feet?
___ Yes ___ No
10. What personal protective equipment is recommended?
___ Gloves ___Foot Protection ___ Hard hat
___ Other _____________________

11. Are there sources of motion which expose employees to impact hazards such as chipping, grinding, masonry work, woodworking, sawing, drilling, chiseling, power fastening, riveting, sanding, etc. in this work area?
___ Yes ___ No
12. Do employees work around or under conveyor belts which carry equipment or machinery? ___ Yes ___ No
13. Is there a possibility of an employee being struck by a falling object?
___ Yes ___ No

14. What personal protective equipment is recommended?
___ Gloves ___ Foot Protection ___ Hard Hat
___ Safety Glasses with side shields
___ Goggles ___ Face Shield ___ Other_________________________

15. Are employees exposed to any sources of penetration such as needles, pipettes, syringes, sharp objects, etc.? ___ Yes ___ No
16. Do employees perform any activities where there is a chance of the hands getting cut? ___ Yes ___ No
17. Are there any scrap metals, nails, wires, screws, tacks, or large staples being used by an employee? ___ Yes ___ No
18. Is there any area where an employee walks where sharp objects may pierce the feet? ___ Yes ___ No
19. What personal protective equipment is recommended?
___ Gloves ___ Safety glasses ___ Goggles ___ Foot Protection
___ Face Shield ___ Other__________________________

20. Are there any sources of high temperature in the work area such as boilers, furnace operations, glass making, cutting, welding, or casting?
___ Yes ___ No
21. Are there any sources of extreme cold temperatures in the work area such as cryogenic gases, dry ice, etc.? ___ Yes ___ No
22. What personal protective equipment is recommended?
___ Gloves ___ Face Shields ___ Safety Glasses ___ Goggles
___ Other____________________

23. Are there any activities performed in areas where high intensity light exists such as arc welding, torch blazing, UV light, infrared spectrometry, or x-rays? ___ Yes ___ No
24. Are lasers used in the work area? ___ Yes ___ No
25. Are heating operations performed? ___ Yes ___ No
26. Is there excess solar glare? ___ Yes ___ No
27. What personal protective equipment is recommended?
___ Filter Lenses ___ Goggles ___ Face shield ___ Welding helmet
___ Other__________________

Other Considerations:
28. Does an employee where contact lenses? ___ Yes ___ No
29. Does an employee where prescription eyewear? ___ Yes ___ No
30. Is an employee allergic or sensitive to certain materials, such as powdered gloves?___ Yes (List___________________________________)
___ No

Personal protective equipment must be selected to protect the affected employees from the hazards identified. The personal protective equipment must fit properly. Defective or damaged PPE must not be used. The cost of implementation and maintenance of PPE is the responsibility of the Department or Administrative Unit.

The Department or Administrative Unit is also responsible for training. The employee must be trained to know when the PPE is necessary; what PPE is necessary; how to properly don, doff, adjust and wear the PPE; the limitations of the PPE; and the proper care, maintenance, useful life, and disposal of the PPE. The employee must demonstrate an understanding of the training before being allowed to perform work requiring the use of the PPE. All training must be documented (name of employee trained, date, subject, person who performed training). Retraining is required if changes occur in the workplace rendering previous training obsolete, if there are changes in the PPE to be used, or if the employee shows indications that he/she has not retained the requisite understanding or skill in order to properly use the assigned PPE.
I, ____________________________________(Print Name of Person performing this assessment), certify that this assessment is complete to the best of my knowledge.

Signature:_____________________________________ Date:_________________

I, ____________________________________(Print Name of Department Head), assure the following:

___ That appropriate PPE is available and maintained in good condition for the employees in my Department.

___ That all affected employees have been trained to know:
a) what PPE is to be worn while performing hazardous tasks.
b) the limitations of the PPE including its proper care, maintenance and useful life.
c) how to properly wear and adjust the PPE required for the task.

Signature:___________________________________ Date:___________________

Citation information:

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