Company Name:__________________________________________________________________________
Location:_________________________________________________________________________________
Job Task(s):______________________________________________________________________________
HAZARD - EYE/FACE
______Flying Objects
______Splash (Metals)
______Splash (Chemicals)
______Dusts
______Mists
______Gas Welding (Shade 4-8)
______Cutting/Torch (Shade 3-6)
______Brazing (Shade 3-4)
______Weld/Electric (Shade 10-14)
______Other:____________________
SELECTION OF PPE
______Spectacle
______Spectacle w/Side Shield
______Face Shield
______Goggles
______Sealed Goggles
______Welding Helmet
______Welding Shield
______Other:__________________
HAZARD SEVERITY
______CAT I: Catastrophic - Hazard may cause death.
______CAT II: Critical - May cause severe injury, severe illness or disability
______CAT III: Marginal - May cause minor injury or minor illness
______CAT IV: Negligible - Probably would not cause injury or minor illness
MISHAP PROBABILITY
_____A Likely to occur immediately or wihtin a short period of time
_____B Probably will occur in time
_____C May occur in time
_____D Unlikely to occur
HAZARD - HEAD
______Falling Objects
______Electrical Shock
SELECTION OF PPE
______Class A (<2,000 volts)
______Class B (>2,000 volts)
______Class C (Conductive)
HAZARD SEVERITY
______CAT I: Catastrophic
______CAT II: Critical
______CAT III: Marginal
______CAT IV: Negligible
MISHAP PROBABILITY
_____A Likely to occur immediately or wihtin a short period of time
_____B Probably will occur in time
_____C May occur in time
_____D Unlikely to occur
HAZARD - FOOT
______Falling Objects
______Rolling Objects
______Piercing Sole
______Electrical Hazard
______Metatarsal Protection
SELECTION OF PPE
______Safety Tip Shoes
______Safety SHoes w/metataursal protection
______Other
HAZARD SEVERITY
______CAT I: Catastrophic
______CAT II: Critical
______CAT III: Marginal
______CAT IV: Negligible
MISHAP PROBABILITY
_____A Likely to occur immediately or wihtin a short period of time
_____B Probably will occur in time
_____C May occur in time
_____D Unlikely to occur
HAZARD - HAND
_____Chemical Sorption
______Chemical Burns
______Abrasions
______Punctures
______Thermal Burns
______Temperature Extremes
SELECTION OF PPE
______Leather Gloves
______Kevlar Gloves
______Cryogenic Gloves
______Chemical Gloves - Material____________________
______Other____________________Cloth gloves are also acceptable
HAZARD SEVERITY
______CAT I: Catastrophic
______CAT II: Critical
______CAT III: Marginal
______CAT IV: Negligible
MISHAP PROBABILITY
_____A Likely to occur immediately or wihtin a short period of time
_____B Probably will occur in time
_____C May occur in time
_____D Unlikely to occur
Certified By:_____________________________________________ Date:_____________________________________