Ppe Assessment Form Examples

Personal Protective Equipment
Hazard Assessment Certification

Job Title: Custodial Worker Date: 10/16/00
Department: Physical Plant Supervisor:
Location / Worksite: Analysis: Dave Erickson
Employee Name(s): Signature:
Tasks, Job Classification Potential Hazard Type of PPE Required PPE Required
or Workstation (Yes / No)
Mixing of bulk chemicals from Splash of concentrated chemicals Goggles, faceshields, rubber gloves, apron. Y
transfer towers
Pigeon Waste Histoplasmosis 1/2 respirator (HEPA cartridges), rubber gloves. Y

Job Title: Maintenance Worker, Mechanic Date: 10/16/00
Department: Physical Plant, Service Garage Supervisor:
Location / Worksite: Analysis: Dan Beachnau
Automobile/Heavy Equipment Flying particles, petroleum Safety glasses, chemical resistant gloves Y
Mechanic Work solvents and wastes
Locksmith Work Flying particles Safety glasses, face shield when using high Y
speed tools
Wood Working Work (Shop) Noise, flying particles, Hearing protection, safety glasses, face shield for Y
lifting/carrying, rough surfaced high speed tools, puncture/cut resistant gloves,
materials safety shoes, guards in place
Metal Working Work (Shop) Noise, flying particles, Hearing protection, safety glasses, face shield for Y
lifting/carrying, rough surfaced high speed tools, puncture/cut resistant gloves,
materials, metal working safety shoes
chemicals
Painting (Shop) Vapors, mists, solvents and Organic vapor respirator w/paint pre-filter, Y
chemical, flammables chemical resistant gloves
Upholstery Work (Shop) Solvents, glues, punctures Chemical resistant gloves Y

Job Title: Maintenance Worker Date: 10/16/00
Department: Power Plant, Housing Supervisor:
Power Plant Work Hot surfaces, contact with Heat resistant gloves, hard hats, hearing Y
surfaces (head), noise protection
Power Plant Laboratory Work Corrosive chemicals, splashing Safety glasses, chemical resistant gloves, apron. Y
chemicals When pouring large quantities of chemicals, a
face shield and goggles
Tunnel Work Contact (head), restricted access Hard hat, light clothing, temperature resistant Y
areas, heat stress, hot surfaces gloves, safety glasses
Elevator Maintenance Work Uncovered electrical switches and Electrically insulated gloves (rated for energized Y
circuits, falling, moving machinery voltage), fall protection, cut/puncture resistant
gloves
Confined Space Work Hazardous atmosphere, restricted Determine appropriate personal protective Y
exit, other depending on nature of equipment in accordance with the Confined
the space Space Entry Program
Department: Physical Plant, Housing, Power Plant Supervisor:
Arc Welding or Cutting Electric shock, metal sparks, Insulating mats or blankets, insulated/heat and Y
molten and hot metal, UV, IR and puncture/cut resistant gloves, safety shoes, hard
visible light, falling, dropping, hat, safety glasses, welding shield or helmet with
rolling and sharp objects appropriate eye shade.
Oxy-fuel Welding or Cutting Metal sparks, molten and hot Heat and puncture/cut resistant gloves, safety Y
metal, UV, IR and visible light, shoes, hard hat, safety glasses, welding shield or
falling, dropping, rolling and sharp helmet with appropriate eye shade.
objects
Torch Brazing Metal sparks, molten and hot Heat and puncture/cut resistant gloves, safety Y
metal, UV, IR and visible light, shoes, hard hat, filer lens spectacles or goggles,
falling, dropping, rolling and sharp or safety glasses and hand shield, with
objects appropriate eye shade (at least #3).
Torch Soldering Molten and hot metal, UV, IR and Heat and puncture/cut resistant gloves, flame Y
visible light, falling, dropping, resistant clothing, safety shoes, hard hat, filter
rolling and sharp objects lens spectacles or goggles, or safety glasses and
hand shield, with appropriate eye shade (at least
#2).
Metal Grinding or Chipping Metal sparks and chips, falling, Heat and puncture/cut resistant gloves, typical Y
dropping, rolling and sharp work clothing, safety shoes, safety glasses, full
objects face shield.
Department: Physical Plant, Power Plant, Housing Supervisor:
Carpentry Work (Construction Site) Flying particles, falling, falling Safety glasses, safety shoes, hard hat, Y
objects, cuts/punctures, cut/puncture resistant gloves, fall protection
lifting/carrying when working at elevations. When using high
speed power tools, a face shield.
Masonry Work (Construction Site) Flying particles, falling, falling Safety glasses, safety shoes, hard hat, Y
objects, cuts/puncture, cut/puncture resistant gloves, fall protection
Laborer Work (Construction Site) Flying particles, falling, falling Safety glasses, safety shoes, hard hat, Y
Painting Work (Construction Site) Flying particles, falling, falling Safety glasses, safety shoes, hard hat, Y
lifting/carrying, cleaning solvents when working at elevations. When using high
Roofing Work Falling, hot surfaces, heat and Safety glasses, safety shoes, fall protection, heat Y
cold stress, sealing chemicals, resistant gloves, chemical resistant gloves.
solvents, lifting/carrying Temperature stress protective clothing,
depending on weather conditions.
Sheet Metal Work (Construction Flying particles, lifting/carrying, Safety glasses, safety shoes, puncture/cut Y
Site) rough surfaced materials resistant gloves. When using high speed power
tools, a face shield.
Low Voltage Electrified Equipment Electric shock, falling Electrically insulated gloves (rated for voltage of Y
Work energized equipment), insulated blankets or
mats non-synthetic work clothing fall protection
mats, non-synthetic work clothing, fall protection
when working at elevations.
High Voltage Electrified Equipment Electric shock, arc, explosion and Hard hat, safety glasses, face shield, insulated Y
Work burns, falling, confined spaces, gloves (rated for voltage of energized
vehicles in traffic areas equipment), insulated blankets or mats, non-
synthetic work clothes, safety shoes, fall
protection when working at elevations, reflective
clothing when working near traffic.
Department: Physical Plant, Housing Supervisor:
Air Conditioning/Refrigeration Work Water treatment chemicals Chemical resistant gloves, safety glasses. When Y
using large quantities of chemicals, a face shield
& goggles
Plumbing Work Hot surfaces, rough surfaced Heat resistant gloves, safety glasses, Y
materials, sewage cut/puncture resistant gloves, rubber gloves
General Maintenance Work Rough surfaced materials, Cut/puncture resistant gloves, safety glasses, Y
lifting/carrying safety shoes
Custodial Work Cleaning chemicals, splashes Chemical resistant gloves, safety glasses. When Y
pouring large quantities of chemicals, a face
shield & goggles.
Refuse Work Noise, sharp objects, garbage Hearing protection, safety glasses, cut/puncture Y
resistant gloves, rubber gloves, safety shoes
Grounds Keeping Work Pesticides, noise, flying particles, Hearing protection, safety glasses, protection Y
heat stress, insect and plants from pesticides according to label, application,
toxins and reentry requirements, skin protection from
insects and plants, safety shoes, gloves
Pest Management Work Pesticides, animals and plants Protection from pesticides according to label, Y
application, and reentry requirements, skin
protection from animals and plants, safety
glasses
Tree Trimming work Pesticides, falling, noise, flying Fall protection, hearing protection, protection Y
particles, heat stress, insect and from pesticides according to label, application,
plant toxins and reentry requirements skin protection from
plant toxins and reentry requirements, skin protection from
insects and plants, safety shoes, safety glasses,
gloves
Moving Work Lifting/carrying Safety shoes Y
Department: Physical Plant Supervisor:
Plumbing Work Hot surfaces, rough surfaced Heat resistant gloves, cut/puncture resistant Y
materials, sewage gloves, rubber gloves, safety glasses
General Maintenance Work Rough surfaced materials, Cut/puncture resistant gloves, safety shoes, Y
lifting/carrying safety glasses
Machine Tools (drills, grinders and Flying particles Safety glasses Y

saws)
Arc Welding or Cutting Electric shock, metal sparks, Insulating mats or blankets, insulated/heat and Y
molten and hot metal, UV, IR and puncture/cut resistant gloves, safety shoes, hard
visible light, falling, dropping, hat, safety glasses, welding shield or helmet with
rolling and sharp objects appropriate eye shade
Moving Work Lifting/carrying Safety shoes, gloves Y
Job Title: Scenic Carpenter Date: 10/16/00
Department: Theatre Supervisor:
Location / Worksite: Auditorium, Wharton Analysis: Dan Beachnau
Operating saws and other power Eye hazard, cuts from blade Safety glasses with side shields (hearing Y
tools protection), guard in place
Operating metal saw Eye hazard and skin hazard Safety glasses with side shields and face shield, Y
Long cuffed leather gloves
Welding Eye hazard, Hand and skin Welding helmet with appropriate shade Y
hazard protection, Long cuffed leather gloves
Moving wood and metal pieces, Foot hazard, dropping objects and Leather work shoe/boot with thick sole, gloves Y
lifting piercing objects, wood splinter,
pinch
Job Title: Grounds Keeper Date: 10/16/00
Department: Housing, Grounds, Physical Plant Supervisor:
Location / Worksite: Campus, Stadium Analysis: Dan Beachnau
Use of powered ground keeping Skin and eye damage Safety glasses, long sleeved shirts, long pants, Y
equipment; lawn mowers, weed cloth gloves
whips, chainsaw etc
Conducting any type of activities on Impact Hard hat Y
an active fairway. Conducting
activities with the potential for
materials to be dropped onto head.
Trash Clean up Dust, cuts, noise Mask, gloves, ear protection Y
Use of Pruning devices Cuts Gloves Y

Job Title: Laboratory Worker Date: 09/17/03
Department: All Supervisor:
Location / Worksite: Research Buildings Analysis: Dave Erickson
Working with low hazard chemicals Skin and eye irritation Safety glasses, Light chemical resistant gloves, Y
when a low probability of splash Lab coat, closed shoe, pants
exists
Working with smaller amounts ( <1 Skin and eye damage Chemical splash goggles, Light chemical
liter) of corrosive or injurious resistant gloves, Lab coat, closed shoe, pants
chemicals where a reasonable
probability of splash exists
Working with larger quantites of Large surface area skin and eye Chemical splash goggles & face shield, Y
corrosive liquids ( > 1 liter), or toxic damage, Poisoning, or Appropriate heavy resistant gloves
corrosives Great potential for eye and skin Lab coat, closed shoes, pants and chemical
damage resistant apron
Working with small volumes of Skin and eye damage Safety glasses, goggles if splash hazard exists, Y
organic solvents (< 1 liter) Slight poisoning potential through Light chemical resistant gloves
skin absorption Lab coat, closed shoe, pants
Working with large volumes of Major skin and eye damage Safety goggles & face shield Y
organic solvents ( > 1 liter), highly Potential poisoning through skin Appropriate heavy resistant gloves
toxic organic solvents or work absorption Above clothes and chemical resistant apron
which may create a splash hazard
Working with small volumes of Potentially infected with infectious Safety glasses Y
human blood, body fluids or other disease (BBP) Disposable nitrile gloves
potentially infectious materials Potential spread of infectious Lab coat, closed shoe, pants
(OPIM) as defined in the MSU disease
Bloodborne Pathogen Exposure
Control Plan
Working with large volumes of Increase potential of becoming Safety goggles & face shield Y
human blood, body fluids or other infected with infectious disease Nitrile gloves
other potentially infectious (BBP) Lab coat, closed shoe, pants
materials and/or splash hazards Increased potential spread of Coveralls and foot covers may be necessary
infectious disease
Working with hazardous powders Potential skin and eye damage, Safety glasses Y
Potential for poisoning through Goggles for large quantities
skin absorption Light chemical resistant gloves
Lab coat, closed shoe, pants
Working with acutely toxic Great potential skin and eye Safety goggles Y
hazardous powders damage Appropriate chemical resistant gloves
Great potential for poisoning Lab coat, closed shoe, pants
through skin absorption Coveralls and booties if necessary
Working with dispersible Potential tissue damage Appropriate eye protection, Y
radioactive materials Potential spread of radioactive Disposable nitrile gloves
contamination Lab coat, closed shoe, pants
Working with radioactive chemicals See appropriate chemical section Safety glasses, goggles for splash hazard Y
(corrosives, solvents, toxics, etc.) above Light chemical resistant gloves
Potential tissue damage Lab coat, closed shoe, pants
Potential spread of radioactive Use PPE for applicable tasks above
contamination
Working with radioactive human Potential tissue damage Safety glasses, goggles for splash hazard Y
blood, body fluids or other Potential spread of radioactive Disposable nitrile gloves
potentially infectious materials contamination Lab coat, closed shoe, pants
Potential exposure to OPIM
Working with sealed radioactive Damaged or leaking source may Safety glasses, light gloves, shield may be Y
sources spread contamination, Some needed for high energy sources
leaking sources may pose an
external does risk.
Working with crygenic liquids Major skin, tissue and eye Chemical splash goggle and face shield Y
damage Heavy insulated gloves
Working with very cold materials Frostbite Safety glasses Y
and equipment (freezers, dry ice) Hypothermia Insulated gloves and warm clothing
Working with hot liquids, equipment Skin damage Safety glasses or goggles for large volumes or Y
and/or open flames (autoclave, Eye damage splash hazards
bunsen burner, waterbath, oil bath) Insulated gloves
Working with large volumes of hot, Major skin and eye damage Safety glasses or goggles and face shield Y
cold, or cryogenic liquids Frozen or burned body tissues Heavy insulated gloves
Above clothes and apron or coveralls
Working with Ultraviolet Radiation Conjunctivitis UV face shield and goggles Y
Corneal eye damage Lab coat, closed shoe, pants
Erythema
Working with LASER radiation Retinal eye damage Appropriate shaded goggles with optical density Y
Skin damage based on individual beam parameters
No jewelry/reflective items allowed
Working with Infrared emitting Cataracts and flash burns to Appropriate shaded goggles, Lab coat, closed Y
equipment (glass blowing) cornea shoe, pants
Arc/TIG welding Conjunctivitis Appropriate shaded goggles Y

Corneal eye damage Working gloves
Erythema
Instrument or equipment Eye damage from foreign objects Safety glasses Y
repair/service No loose clothing or jewelry
Metal working/Woodworking shop Eye damage from foreign objects Safety glasses Y
No loose clothing or jewelry
Glassware washing Skin lacerations Safety glasses, Heavy rubber gloves Y

Working in Industrial lab with Head injury, foot injury Hard-hat Y

potential injury from falling Steel toe boots
equipment or tools (ex. Earthquake
lab, Structural Engineering lab, etc.)
Spill clean-up See potential hazards for See applicable individual task section Y
applicable task section
Changing Cryostat knife blade Skin lacerations Skin lacerations Y

Potential infection by BBP Potential infection by BBP
Job Title: Farm Worker Date: 10/02/00
Department: Farms / Land Management Supervisor:
Location / Worksite: State Wide Analysis: Dan Beachnau
Farm Worker Falls From machinery Training on safe mount/dismount No
Farm Worker Powered shafts/belts Disengage power for routine maintenance, Yes
gloves, lockout tag for extensive repair
Farm Worker Sun burn, heat stress, frost bite Training, proper clothing, sunscreen Yes
Transport of equipment on Traffic crash Traning on safe driving, Slow Moving Vehicle No
highway/roads signs on equipment
Use of forks, shovels Foot injury Leather shoes or boots Yes
Farm Worker Rolling equipment could crush Training, park or wheel chocks No
body/limbs
Mixing/application of Splash to face Gloves, goggles Yes

Chemicals/Herbicides
Job Title: Tree Trimmer Date: 10-2-00
Department: Grounds Supervisor:
Operating hand saw, chainsaw and Impact Impact approved safety glasses or goggles and Y
wood chipper faceshield
Trimming activities in, under, or Falling or rolling objects, splinters, Hard had and safety boot, leather palm gloves Y
around trees cuts, abrasions

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Personal Protective Equipment

Hazard Assessment Certification

Pigeon Waste Histoplasmosis 1/2 respirator (HEPA cartridges), rubber gloves. Y

Upholstery Work (Shop) Solvents, glues, punctures Chemical resistant gloves Y

Machine Tools (drills, grinders and Flying particles Safety glasses Y

Use of Pruning devices Cuts Gloves Y

Arc/TIG welding Conjunctivitis Appropriate shaded goggles Y

Glassware washing Skin lacerations Safety glasses, Heavy rubber gloves Y

Working in Industrial lab with Head injury, foot injury Hard-hat Y

Changing Cryostat knife blade Skin lacerations Skin lacerations Y

Use of forks, shovels Foot injury Leather shoes or boots Yes

Mixing/application of Splash to face Gloves, goggles Yes

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