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Site Specific Job Hazard Assessment Form

Name of project: __________________________________


Company: _________________________
EYES

Work Activities

Work activities, such as:


abrasive blasting
chopping
cutting
drilling
welding
punch press operations
other: _______________________________

FACE
Work activities, such as:
cleaning
siphoning
painting
other________________________________

Completed by:___________________________
Possible Health Hazards

Date:

Hazard Control / Injury Prevention Methods

Work-related exposure to:


airborne dust
sanding
flying particles
blood splashes
hazardous liquid chemicals
intense light
other: _______________________

Can hazard be eliminated without the use of PPE?


Yes
No
sawing
If no,grinding
use:
Safety
hammering
glasses
Safety goggles
Shading/Filter (#
)
Welding shield
Other: _______________________________

Work-related exposure to:


hazardous liquid chemicals
extreme heat/cold
welding
potential irritants: -______________
mixing
other: _______________________

Can hazard be eliminated without the use of PPE?


Yes foundry
No work
If no, use:
Face
pouring
shield
molten
Shading/Filter (#
)
Welding shield
Other: _________________________________

HEAD
Work activities, such as:
building maintenance
confined space operations
construction
electrical wiring
walking/working under catwalks
walking/working under conveyor belts
walking/working under crane loads
utility work
other: _______________________________

Work-related exposure to:


Can hazard be eliminated without the use of PPE?
beams
Yes
No
pipes
exposed electrical wiring/ components If no, use:
falling objects
Protective Helmet
machine parts
Type A (low voltage)
other: _______________________
Type B (high voltage)
Type C
Bump cap (not ANSI-approved)
Hair net or soft cap
Other: ________________________________

HANDS/ARMS
Work activities, such as:
grinding
welding
working with glass
using computers
using knives
other: _______________________________

Work-related exposure
material
to: handling
blood
sawing
irritating chemicals hammering
tools or materials that could scrape,
bruise, or cut
extreme heat/cold
other: ________________________

Can hazard be eliminated


sanding without the use of PPE?
Yes
No

Work-related exposure to:

Can hazard be eliminated without the use of PPE?


Yes
No

If no, use:

Gloves
Chemical resistance
Liquid/leak resistance
Temperature resistance
Abrasion/cut resistance
Slip resistance
Protective sleeves
Other: _______________________________

FEET/LEGS
Work activities, such as:
building maintenance
construction
demolition
plumbing
trenching
use of highly flammable materials
welding
other: ______________________________

BODY/SKIN
Work activities such as:
battery charging
fiberglass installation
irritating chemicals
sawing
other: _______________________________

explosive atmospheres
explosives
If no, use:
exposed electrical wiring /components
Safety shoes or boots
heavy equipment
Toe protection
slippery surfaces
Electrical protection
Heat/cold protection
tools
Puncture resistance
Chemical resistance
other: _______________________
Anti-slip soles
Leggings or chaps
Foot-Leg guards
Other: ________________________________

Work-related exposure to:


chemical splashes
extreme heat/cold
sharp or rough edges
other: _______________________

Can hazard be eliminated without the use of PPE?


Yes
No
If no, use:

Vest, Jacket
Coveralls, Body suit
Raingear
Apron
Welding leathers
Abrasion/cut resistance
Other: ________________________________

Body/Whole
Work activities such as:

Work-related exposure to:

building maintenance
construction
utility work
other: ______________________________

working from heights of 10ft or more


working near water
other: ________________________

Can hazard be eliminated without the use of PPE?


Yes
No
If no, use:

Fall Arrest/Restraint:
Type:______________
PFD: Type:
_________________________
Other: _________________________________

LUNGS/RESPIRATORY
Work activities such as:

Work-related exposure to:

cleaning
pouring
mixing
sawing
painting
fiberglass installation
compressed air or gas operations
other: ________________________

irritating dust or particulate


irritating or toxic gas/vapor
other: ______________________

Can hazard be eliminated without the use of PPE?


Yes
No
If no, use:
Respirator*
*Please note in the space below the appropriate type, including
manufacturer model & class of respirator being used for this job.

EARS/HEARING
Work activities such as:
generator
ventilation fans
motors
sanding
pneumatic equipment
punch or brake presses
other:__________________

Work-related exposure to:


grinding
machining
routers
sawing

loud noises
loud work environment
noisy machines/tools
punch or brake presses
other: ____________________

Can hazard be eliminated without the use of PPE?


Yes
No

If no, select appropriate protection grade level for


noise:
Ear Plugs
Ear Muffs
Other ________________________

Additional Notes:

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