HAZARD ASSESSMENT FORM

Instructions: Print  this form and keep the original for future 
hazard assessments.  Use a copy as a guide for your walk-through survey. 
It will help you identify the hazards in each work area.  Once you've 
completed the form you are ready to select the appropriate PPE.  Submit 
this form to EHSC with your safety plan and/or updates.


Area:______________________________ Job Classification:___________________

Assessor:___________________________   Date:______________________________



HEAD HAZARDS: Tasks that can cause head hazards include: Working 
below other workers who are using tools and materials which could fall, 
working on energized electrical equipment, working with chemicals, and 
working under machinery or processes which might cause materials or objects 
to fall.

Circle the appropriate box for each hazard:

Burn			Yes	No    Description of hazards:_____________
Chemical Splash	        Yes	No    ____________________________________
Electrical Shock	Yes	No    ____________________________________
Impact			Yes	No    ____________________________________

EYE HAZARDS: Tasks that can cause eye hazards include: Working with 
acids and chemicals, chipping, grinding, furnace operations. Sanding, 
welding, and woodworking.

Check the appropriate box for each hazard:

Chemicals		Yes	No    Description of hazards:_____________
Dust			Yes	No    ____________________________________
Heat			Yes	No    ____________________________________
Impact			Yes	No    ____________________________________
Light/Radiation		Yes	No    ____________________________________

HAND HAZARDS: Tasks that can cause hand hazards include: cutting 
material, working with chemicals and working with hot objects.

Check the appropriate box for each hazard:

Burns			Yes 	No    Description of hazards:_____________
Chemical Exposure	Yes	No    ____________________________________
Cuts/Abrasion		Yes	No    ____________________________________
Puncture		Yes	No    ____________________________________

FOOT HAZARDS: Tasks that can cause foot hazards include: Carrying 
or handling materials that could be dropped, performing manual material 
handling and working with chemicals.

Check the appropriate box for each hazard:

Chemical Exposure	Yes	No    Description of hazards:_____________
Compression		Yes	No    ____________________________________
Impact			Yes	No    ____________________________________
Puncture		Yes	No    ____________________________________







Guidelines for Selecting Personal Protective Equipment 
(PPE)

Note: PPE alone should not be relied on to provide protection against 
hazards, but should be used in conjunction with guards, engineering 
controls and sound manufacturing practices.


1. Familiarize yourself with the potential hazards in the are and the types 
   of PPE that are available

2. Consider the hazards associated with the environment (impact velocities,
   masses, projectable shape, radiation intensities)

3. Select PPE that ensures a greater level of protection than the minimum 
   required to protect workers from the hazards.

4. Fit the worker with the PPE and give instructions on its use and care. 
   It is very important that workers be made aware of all warning labels 
   for and limitation of their PPE.

Based on the hazard assessment for _______________________, the 
                                     (Job Classification)
following PPE is required:


      EYE HAZARD		   JOB	                      PPE
_______________________   _______________________   _______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________

      HEAD HAZARD		   JOB			      PPE
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________

      FOOT HAZARD		   JOB		              PPE
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________

      HAND HAZARD		   JOB			      PPE
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________

      OTHER			   JOB			      PPE
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________
_______________________   _______________________   ______________________