PPE Hazard Assessment Risk Analysis

Department: 	

Job Task:	Date:	Performed by:  	

	Y/N	Hazard Source	Hazard Severity	Hazard Probability	Hazard Duration	Hazard Index	Appropriate PPE	Comments
(Identify Hazards and Controls)	
Eye & Face Protection	
Exposed to fl	particles, potential to injuries such as punctures, contusions or burns.									
Exposed to liquid chemicals, acids/caustic liquids, chemical gases or vapors or potentially harmful light radiation									
Note: In addition to wearing a face shield, the use of safety glasses/goggles is required.	
Head Protection	
Potential for injury from a fl	or falling object or overhead hazards.									
Hazardous chemicals are present									
Exposure to electric shock, burns or electrical conductors									
Potential to get caught in objects or equipment									
Foot Protection	
Potential for foot injury due to an object piercing the sole of the shoe									
Potential for falling or rolling objects to impact the foot									
Floor surfaces are slippery									
Hand Protection	
Hands are exposed to hazardous substances, chemical burns or harmful temperature extremes									
Potential for hand injuries from cuts, lacerations or punctures									
Body Protection	
Exposed to harmful materials, chemicals, extreme temperatures or a source of cuts, lacerations or punctures									

Refer to the next page Hazard Index Risk Model Criteria for checklist completion

PPE Hazard Assessment certified by (Signature): 	

Risk Model Criteria
Assessing basic hazards, exposure sources, and then calculating the Hazard Probability, Duration and Severity and if there is a need for Personal Protective Equipment.
Example: Hazard Index Calculation: Severity(4) + Probability(4) + Duration(3) = 11*
*PPE is required. Engineering modifications are strongly recommended where feasible.

Hazard Severity	
Critical
May cause debilitating injury, illness or fatality
E.g.: amputations, broken bones, fractures, concussions	
4	
Significant
May cause severe injury or illness
E.g.: stitches, sutures, lacerations, severe rashes, second-degree burns and eye injuries	
3	
Marginal
May cause minor injury or illness
E.g.: general first aid, abrasions	
2	
Negligible
Probably would not affect personnel or may cause minor first aid visit	1	

 	
Hazard Probability	
Likely to Occur	4	
Probably Will Occur	3	
May Occur	2	
Unlikely to Occur	1	

Hazard Duration	
Continuous
Throughout entire shift	4	
Routine
Several times throughout a shift	3	
Periodic
Intermittent exposure	2	
Sporadic
Less than intermittent	1	

Hazard Index Classification	
PPE is required.	9 to 12	
PPE is strongly recommended.	6 to 8	
PPE may not be necessary.	3 to 5	

Hazard Sources Examples

•	Motion
•	Extreme Temperatures
•	Acids, Caustics, Oils
•	Solvents, Reactants
•	Dust and Fibers
•	Flying Objects
•	
Light Radiation
•	Falling Objects
•	Sharp Objects
•	Rolling Hazards
•	Pinching Hazards
•	Electricity
•