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11F-OEHS /Tulane (Rev 8/03) PPE PERSONAL PROTECTIVE EQUIPMENT ASSESSMENT This assessment form shall be used to assess the hazards to which employees may be exposed to determine whether there are hazards in the environment that necessitate the use of personal protective equipment. Departments and Administrative Units are responsible for completing and submitting this form to the Office of Environmental Health and Safety. (A separate assessment form must be completed for each work area). Person(s) Conducting the Assessment:__________________________________________________________ Department: ________________________________ Phone No/Ext: ___________________________________ e-Mail: _____________________________________________________ Mail Code:_____________________ Location of Area to Be Assessed: Campus: _______________________ Building:____________________________ Room No: ______________ (Campus: e.g., Uptown, TUHSC, Primate, etc.) Date of Assessment: _____/_____/_____ CHEMICAL OR INFECTIOUS HAZARDS 1. Are hazardous chemicals or infectious materials used in this work area? ___Yes___No 2. What types of hazardous chemicals or materials are used? (Check all that apply.) ___ Corrosives ___ Flammables ___ Toxics ___ Oxidizers ___ Biohazards ___ Carcinogens (please list)____________________________________________________ ___ Explosives ___ Radioactive Materials ___ Infectious Agents ___ Other(s) (please list)__________________________________________________ 3. What personal protective equipment is recommended for use with these materials? (See Material Safety Data Sheets or other sources of information) (Check all that apply.) ___ Gloves ___ Chemical Apron ___ Respirator ___ Goggles ___ Lab coat ___ Safety Glasses ___ Face Shield ___ Shoe Covers ___ Other(s) ____________________________________________ HARMFUL DUST 1. Are there sources of harmful dust to which employees may be exposed (such as from blasting, buffing, woodworking, mixing of concrete and/or glazes for art, etc.) in this work area? ___ Yes ___ No 2. What personal protective equipment is recommended (see Material Safety Data Sheets or other sources of information)? (Check all that apply.) ___ Gloves ___ Dust/Mist Respirator ___Safety Glasses ___Goggles ___ Face Shield ___ Other(s) ____________________________________________________ COMPRESSION 1. Are there activities in which employees may encounter compression hazards such as from hydraulic jacks, tools, presses, or compactors in this work area? ___Yes___No 2. Are forklifts used in this work area? ___Yes___No 3. Do employees install or work with heavy pipes in this work area? ___ Yes___No 4. Are there objects in the work area that may roll over an employee's feet? ___Yes___No 5. What personal protective equipment is recommended? ___ Gloves ___Foot Protection ___ Hard Hat ___ Other(s) _____________________________ Fill out the form online and print, then mail to OEHS - TW16.
