Certificate of Hazard Assessment | Personal Protective Equipment
All managers and supervisors must survey the work areas and activities under their control to
determine where personal protective equipment, or PPE, may be required.
Instructions: Identify the workplace location. Conduct a walk through survey of the workplace
and list the task or job functions that require PPE. Ensure PPE has an acceptable ANSI rating
based on the chart provided on the back of this sheet. Conduct interviews with employees while
performing field observations when necessary and complete this form. Sign and date this
certificate. The completed certificate should remain on file in your area as well as additional
areas required by your department.
Please note:
When determining if a potential hazard exists, consideration should be given to the following:
Employee’s perception of hazards.
History of employee complaints or concerns.
History of injuries or illnesses related to the workplace or job.
Location Department
Potential hazard
PPE required
Are employees wearing PPE
appropriate to tasks?
Yes No
Is PPE worn and adjusted
Yes No
Is PPE maintained in good
Yes No
If no, describe corrective action taken:
I, certify that the above location has been evaluated for
potential hazards, the appropriate PPE and that training has been performed.
Signature of Assessor Date
PPE criteria
*ANSI criteria for protective equipment is as follows:
Protective equipment
Purchased after July 5, 1994
Purchased before July 5, 1994
Eye and face protection
ANSI Z87.1 2020
ANSI Z87.1 1968
Head protection
ANSI Z89.1 2014
ANSI Z89.1 1986
Foot protection
ASTM F 2412-18a 2018
ASTM F 2413-18 2018
ANSI Z41.1 1967
*This form was taken from Arizona State Risk Management training handout for OSHA
1910.132 - Personal Protective Equipment
Questions? Contact ASU Environmental Health and Safety
at 480-965-1823 or email asuehs@asu.edu.
Revision date 9/2/2021
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