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This material is for training purposes only to inform the reader of occupational safety and health best practices and general compliance requirements and is not a substitute for provisions of the OSH Act of 1970 or any governmental regulatory agency.
  MODULE 7: 1910.95 HEARING PROTECTION
Sample Hazard Assessment Forms

The following is a sample workplace hazard assessment form that may be used to satisfy documentation and certification requirements. This sample form was produced by Office of Health and Safety, Centers for Disease Control and Prevention.

Hazard Assessment Certification Form

Date: Location:
Assessment Conducted By:
 
Specific Tasks Performed at this Location:
 
 

Hazard Assessment and Selection of Personal Protective Equipment


I. Overhead Hazards -

  • Hazards to consider include:
  • Suspended loads that could fall
  • Overhead beams or loads that could be hit against
  • Energized wires or equipment that could be hit against
  • Employees work at elevated site who could drop objects on others below
  • Sharp objects or corners at head level
Hazards Identified:
 
 
 
 


Head Protection

Hard Hat: Yes No
If yes, type:
  • Type A (impact and penetration resistance, plus low-voltage electrical insulation)
  • Type B (impact and penetration resistance, plus high-voltage electrical insulation)
  • Type C (impact and penetration resistance)


II. Eye and Face Hazards -

  • Hazards to consider include:
  • Chemical splashes
  • Dust
  • Smoke and fumes
  • Welding operations
  • Lasers/optical radiation
  • Bioaerosols
  • Projectiles
Hazards Identified:
 
 
 
 


Eye Protection

Safety glasses or goggles Yes No
Face shield Yes No


III. Hand Hazards -

  • Hazards to consider include:
  • Chemicals
  • Sharp edges, splinters, etc.
  • Temperature extremes
  • Biological agents
  • Exposed electrical wires
  • Sharp tools, machine parts, etc.
  • Material handling
Hazards Identified:
 
 
 
 


Hand Protection

Gloves Yes No
  • Chemical resistant
  • Temperature resistant
  • Abrasion resistant
  • Other (Explain)
     
     


IV. Foot Hazards -

  • Hazards to consider include:
  • Heavy materials handled by employees
  • Sharp edges or points (puncture risk)
  • Exposed electrical wires
  • Unusually slippery conditions
  • Wet conditions
  • Construction/demolition
Hazards Identified:
 
 
 
 


Foot Protection

Safety shoes Yes No
Types:
  • Toe protection
  • Metatarsal protection
  • Puncture resistant
  • Electrical insulation
  • Other (Explain)


V. Other Identified Safety and/or Health Hazards:

Hazard Recommended Protection
 
 
 
 
  
 
 
 


I certify that the above inspection was performed to the best of my knowledge and ability, based on the hazards present on _______________________.


_______________________
(Signature)