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PERSONAL PROTECTIVE EQUIPMENT QUESTIONNAIRE
The following questionnaire shall be used to assess the hazards to which an employee may be exposed to, determine if there are hazards present in the environment which necessitate the use of personal protective equipment (PPE). It is the responsibility of Departments and Administrative Units to complete this paperwork for each work area and submit it to the Office of Environmental Health & Safety, TW16.
Name of Person Doing Assessment: ______________________________________
Department: ______________________________________
Work Area (Campus, Building, Room #, Other): ______________________________________
Date of Assessment: ______________________________________
Chemical or Infectious Hazards:
Yes No 1. Are hazardous chemicals or infectious materials used in this work area?
2. What types of hazardous chemicals or materials are used? (Check all that apply)
Corrosives ___ Flammables ___ Toxics ___ Oxidizers
Carcinogens (Please list)______________________________________
Poisons ___ Explosives ___ Radioactive Materials
Biohazards ___ Infectious Agents
3. What personal protective equipment is recommended for use with these materials (see Material Safety Data Sheets or other sources of information)?
(Check all that apply)
Gloves ___ Chemical Apron ___ Respirator Goggles
Lab coat ___ Safety Glasses ___ Face Shield ___ Shoe Covers
Other
Harmful Dust:
Yes No 4. Are there sources of harmful dust to which employees may be exposed (such as
from blasting, buffing, woodworking, mixing of concrete and/or glazes for art,
etc.) in this work area?
5. What personal protective equipment is recommended (see Material Safety Data
Sheets or other sources of information)? (Check all that apply)
Gloves ___ Dust/Mist Respirator Safety Glasses Goggles
Face Shield Other ___________________________________
Compression:
Yes No 6. Are there activities in which employees may encounter compression hazards
such as from hydraulic jacks, tools, presses, or compactors in this work area?
Yes No 7. Are forklifts used in this work area?
Yes No 8. Do employees install or work with heavy pipes in this work area?
Yes No 9. Are there objects in the work area which may roll over an employee's feet?
10. What personal protective equipment is recommended?
Gloves ___Foot Protection ___ Hard hat
Other ___________________________________
Impact:
Yes No 11. Are there sources of motion which expose employees to impact hazards such as
chipping, grinding, masonry work, woodworking, sawing, drilling, chiseling,
power fastening, riveting, sanding, etc. in this work area?
Yes No 12. Do employees work around or under conveyor belts which carry equipment or
machinery?
Yes No 13. Is there a possibility of an employee being struck by a falling object?
14. What personal protective equipment is recommended?
Gloves ___ Foot Protection ___ Hard Hat
___ Safety Glasses with side shields
Goggles ___ Face Shield ___ Other_________________________
Penetration:
Yes No 15. Are employees exposed to any sources of penetration such as needles, pipettes,
syringes, sharp objects, etc.?
Yes No 16. Do employees perform any activities where they can cut their hands?
Yes No 17. Are there any scrap metals, nails, wires, screws, tacks, or large staples being
used by an employee?
Yes No 18. Is there any area where an employee walks where sharp objects may pierce the
feet?
19. What personal protective equipment is recommended?
Gloves ___ Safety glasses ___ Goggles ___ Foot Protection
Face Shield Other__________________________
Heat:
Yes No 20. Are there any sources of high temperature in the work area such as boilers,
furnace operations, glass making , cutting, welding, or casting?
Yes No 21. Are there any sources of extreme cold temperatures in the work area such as
cryogenic gases, dry ice, etc.?
22. What personal protective equipment is recommended?
___ Gloves ___ Face Shields ___ Safety Glasses Goggles
Other____________________
Light/Radiation:
Yes No 23. Are there any activities performed in areas where high intensity light exists
such as arc welding, torch blazing, UV light, infrared spectrometry, or x-rays?
Yes No 24. Are lasers used in the work area?
Yes No 25. Are heating operations performed?
Yes No 26. Is there excess solar glare?
27. What personal protective equipment is recommended?
Filter Lenses Goggles ___ Face shield Welding helmet
Other____________________
Other Considerations:
Yes No 28. Does an employee wear contact lenses?
Yes No 29. Does an employee wear prescription eyewear?
Yes No 30. Is an employee allergic or sensitive to certain materials, such as
powdered gloves?___________________________________
Personal protective equipment must be selected to protect the affected employees from the hazards identified. The personal protective equipment must fit properly. Defective or damaged PPE must not be used. The cost of implementation and maintenance of PPE is the responsibility of the Department or Administrative Unit.
The Department or Administrative Unit is also responsible for training. The employee must be trained to know when the PPE is necessary; what PPE is necessary; how to properly don, doff, adjust and wear the PPE; the limitations of the PPE; and the proper care, maintenance, useful life, and disposal of the PPE. The employee must demonstrate an understanding of the training before being allowed to perform work requiring the use of the PPE. All training must be documented (name of employee trained, date, subject, person who performed training). Retraining is required if changes occur in the workplace rendering previous training obsolete, if there are changes in the PPE to be used, or if the employee shows indications that he/she has not retained the requisite understanding or skill in order to properly use the assigned PPE.
I, _____________________________________(Person performing this assessment), certify that this assessment is complete to the best of my knowledge.
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I,_____________________________________(Department Head), assure the following:
That appropriate PPE is available and maintained in good condition for the employees in my Department.
That all affected employees have been trained to know:
a) what PPE is to be worn while performing hazardous tasks. b) the limitations of the PPE including its proper care, maintenance and useful life. c) how to properly wear and adjust the PPE required for the task.
SIGNATURE (Dept Head)._____________________________________ DATE:
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