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
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
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
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