COVID-19:
Non-HCP PPE hazard assessment and certification
Use of this form is for CSUCI Non-Health care personnel/law enforcement (HCP) to identify hazards associated
with work tasks during the current COVID-19 pandemic. Workers should continue to use the PPE, if any, that they
would ordinarily use for other job tasks.
General information
Employee(s) names:
Department:
Jobs included in the assessment:
Manager/Supervisor performing assessment:
Potential hazards
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Close contact with coworker and/or public, being within 6 feet from another person for 10 minutes or longer in an enclosed space.
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Contacting surfaces touched or handled by a person with or suspected COVID-19.
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Close contact with a coworker with COVID-19
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No Hazard identified
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Other:
PPE required
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Cloth face covering
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Surgical mask
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Particulate-removing respirator (N95)
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Gloves
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Goggles
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Face shield
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None required
I certify that I performed this hazard assessment:
Signature: Date:
OSHA workplace safety guidance: OSHA has divided workplaces and work operations into risk zones, according to the likelihood
of employees’ occupational exposure during a pandemic. For Non-HCP, the risk zones identified below are useful in determining
appropriate work practices and precautions.
Lower
Exposure Risk:
• Employees who have minimal occupational contact with the general public and other coworkers (such as office employees).
• Administrative Controls
o Maintain a distance of at least 6 feet
• Personal Protective Equipment:
o Additional PPE is not recommended for workers in the lower exposure risk group.
o Workers should continue to use the PPE, if any, that they would ordinarily use for other job tasks.
Medium
Exposure Risk:
• Employees with high-frequency contact with the general population (such as schools, high density work environments).
• Administrative Controls:
o Minimize face-to-face contact
o Maintain a distance of at least 6 feet
• Personal Protective Equipment (PPE):
o During an outbreak of an infectious disease, such as COVID-19, recommendations for PPE specific to occupations
or job tasks include: gloves, goggles, face shields, face masks, and respiratory protection, when appropriate.
Submit to Human
Resources
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