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)

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