Intructions: Observe the job/task. For each job/task being analyzed, note all possible hazards associated with the body parts listed below. Complete the left side of the form. Look at all steps of a job and ask the employee if there are any variations in the job that are infrequently done and that you might have missed during your observation. For purposes of the assessment, assume that the affected employees are wearing no PPE even though they may actually be wearing what they need to do the job safely. Note all observed hazards. Use the blank space next to each hazard to make notes. This list does not cover all possible hazards that employees may face. If you find additional hazards list them in the “other” space. Analyze the hazard(s) and assign controls. For each job task with a hazard source identified, complete the right side of the hazard assessment form. Try first to reduce employee exposure to the hazard by assigning engineering, work practice and/or administrative controls to the job. Note those measures in the space provided. If these measures don’t completely eliminate the hazard, assign PPE to the job/task by placing a check mark in the box next to the type of PPE needed. If the type of PPE is not listed, check the “other” box and list in the space provided. PPE must be appropriately matched to the hazard so that it provides effective protection. Inform and train all affected staff. Certify the hazard assessment. Sign and date the assessment. Send a copy to the agency safety officer for review, approval and inclusion in the written PPE plan, where applicable.
SECTION 1 – Job Assessment Information
Name of Task or Area Assessed:
Description of Task or Area Assessed:
Location of Assessment
SECTION 2 – Body Part Assessment – Eyes
The eyes are potentially exposed to the following during performance of this task:	The following work practice controls should be used to mitigate exposure:
Airborne Dust
Dirt	In the absence of sufficient workplace controls, the following PPE must to used:
UV, Laser or Other Intense Light (i.e., glare, welding, etc.)	Safety Glasses
Impact from Flying Particles/Objects	Safety Goggles
Impact from Stationary Objects	Tight Goggle (dust)
Splashes from Blood or Other Body Fluids, Chemicals or Hot Liquids	Impact Goggles
Sparks or Flame	Chemical Goggles
Intense Heat	Laser Goggles
Other:	Face Shield
Welding Helmet and Shield with Appropriate Shading Filter
Other:
SECTION 3– Body Part Assessment – Face
The face is potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure risk:
Splashes from Blood or Other Body Fluids, Chemicals or Hot Liquids
Extreme Heat or Cold
Sparks or Flame	In the absence of sufficient workplace controls, the following PPE must to used:
UV Light	Face Shield
Potential Irritants	Welding Shield with Appropriate Shading Filter
Other:	Other:
SECTION 4 – Body Part Assessment – Ears/Hearing
The ears/hearing are potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Impact Noises (momentary explosions of sound more than 140 DB)
Continuous Noise Levels of 90 DB or More
In the absence of sufficient workplace controls, the following PPE must to used:
Hearing Protection Device
SECTION 5 – Body Part Assessment – Head/Neck
The head/neck is potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Falling Objects
Stationary Objects such as pipes, beams and machine parts
Sparks or Flame	In the absence of sufficient workplace controls, the following PPE must to used:
UV Light	Tybe A Hardhat (low voltage)
Muscular Skeletal Strain	Tybe B Hardhat (high voltage)
Other:	Type C Hardhat
Helmet
Ergonomic Equipment
Other:

SECTION 6 – Body Part Assessment – Hands/Arms
The hands/arms are potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Body Fluids, Chemicals or Other Harmful Liquids
Crushing or Pinch Points
Tools, Materials or Objects that could Scrape, Bruise or Cut	In the absence of sufficient workplace controls, the following PPE must to used:
Vibration	Chemical-Resistant Gloves
Electric Shock	Leather Gloves (for abrasion and heat resistance)
Poisonous Plants	Slip-Resistant Gloves
Hot Surfaces, Sparks or Flame	Latex or Nitrile Gloves
Cold or Hot Environmental Temperatures	Anti-Vibration Gloves
Muscular Skeletal Strain	Leak-Resistant Gloves
Other:	Protective Sleeves
Ergonomic Equipment
Other:
SECTION 7 – Body Part Assessment – Feet/Legs
The feet/legs are potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Body Fluids, Chemicals or Other Harmful Liquids
Falling Objects
Tools, Materials or Objects that could Scrape, Bruise or Cut	In the absence of sufficient workplace controls, the following PPE must to used:
Hot Surfaces, Sparks or Flame	Safety Footwear with Toe Protection
Slippery/Wet Surfaces	Safety Footwear with Electrical Protection
Other:	Safety Footwear that is Puncture Resistant
Safety Footwear that has Anti-Slip soles
Safety Footwear that has Metatarsal Protection
Safety Footwear that is Chemical Resistant
Leggings or Chaps
Nomex Pants
Chemical-Resistant Pants
Other:
SECTION 8 – Body Part Assessment – Torso
The body/skin are is potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Body Fluids, Chemicals or Other Harmful Liquids
Hot Surfaces, Chemicals or Other Harmful Liquids
Tools, Materials or Objects that could Scrape, Bruise or Cut	In the absence of sufficient workplace controls, the following PPE must to used:
Extreme Heat	Nomex Clothing
Extreme Cold	Coveralls/Body Suit
Muscular Skeletal Strain	Welding Apron
Other:	Welding Leathers
Outerwear with Long Sleeves
Chemical-Resistant Shirt/Jacket
Ergonomic Equipment
Other:
SECTION 9 – Body Part Assessment – Entire Body
The body is potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Falling from an Elevated Walking or Working Surface
Impact from Flying Objects
Impact from Moving Vehicles	In the absence of sufficient workplace controls, the following PPE must to used:
Impact from Stationary Objects	Fall Arrest System
Sharp Objects	Seat Belt
Body Fluids, Chemicals or Other Harmful liquids	High-Visibility Outerwear
Hot Surfaces, Sparks or Flame	Flame-Resistant Outerwear
Electricity	Other:
Other:

SECTION 10 – Body Part Assessment – Lungs/Respiration
The lungs/respiration ares potentially exposed to the following during performance of this task:	The following work practice controls should be used to reduce exposure:
Dust or Particulate Matter
Toxic Gas/Vapor
Smoke	In the absence of sufficient workplace controls, the following PPE must to used:
Chemical Irritants	Dust Mask
Welding Fumes	Particulate Respirator with Appropriate Cartridge:
Asbestos
Pesticides	PAPR (air recycle)
Oxygen Deficient Environment	PPSA (air supply)
Other:	Face Shield
Other:
SECTION 11 – Signatures and Certification of Assessment
Assessor Name (Print)	Assessor Signature	Date
Control Measures:	Approved	Not approved	Approved with modifications
Safety Officer Name (Print)	Safety Officer Signature	Date