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Site Specific Job Hazard Assessment Form

Name of project: __________________________________________________________________________________________


Company: ________________________________________________ Completed by: ___________________________ Date: _____________
EYES

Work Activities

Work activities, such as:


abrasive blasting
chopping
cutting
drilling
welding
punch press operations
other:

Possible Health Hazards

Hazard Control / Injury Prevention Methods

Work-related exposure to:


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

Can hazard be eliminated without the use of PPE? Yes No


If no, use:
Safety goggles
Shading/Filter (#
)
Safety glasses
Welding Shield
Other:

Work-related exposure to:


hazardous liquid chemicals
extreme heat/cold
potential irritants:

Can hazard be eliminated without the use of PPE? Yes No

FACE
Work activities, such as:
cleaning
siphoning
painting
other:

If no, use:
Face shield
Shading/Filter (#
Welding Shield
Other:

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:


beams
pipes
exposed electrical wiring/ components
falling objects
machine parts
other:

Can hazard be eliminated without the use of PPE? Yes No


If no, use:
Protective Helmet
Type A (low voltage)
Type B (high voltage)
Type C
Bump cap (not ANSI-approved)
Hair net or soft cap
Other:

H A N D S /A R M S

Work activities, such as:


grinding
welding
working with glass
using computers
using knives
other:

Work-related exposure to:


blood
irritating chemicals
tools or materials that could scrape,
bruise, or cut
extreme heat/cold
other:

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:

F E E T /L E G S

Work activities, such as:

Work-related exposure to:

building maintenance
construction
demolition
plumbing
trenching
use of highly flammable materials
welding
other:

explosive atmospheres
explosives
exposed electrical wiring /components
heavy equipment
slippery surfaces
tools
other:

Can hazard be eliminated without the use of PPE?


Yes No
If no, use:
Safety shoes or boots
Toe protection
Electrical protection
Puncture resistance
Anti-slip soles
Leggings or chaps
Foot-Leg guards
Other:

Heat/cold protection
Chemical resistance

B O D Y /S K IN

Work activities such as:

Work-related exposure to:

battery charging
fiberglass installation
irritating chemicals
sawing
other:

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:

B o d y/W h o le

Work activities such as:

Work-related exposure to:

working from heights of 10'ft or more


working near water
other:

building maintenance
construction
utility work
other:

Can hazard be eliminated without the use of


PPE? Yes No
If no, use:
Fall Arrest/Restraint:
Type:
PFD: Type:
Other:

L U N G S /R E S P IR A T O R Y

Work activities such as:

Work-related exposure to:

Can hazard be eliminated without the use of


PPE? Yes No

irritating dust or particulate


irritating or toxic gas/vapor
other:

If no, use:
Respirator*

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

*Please note in the space below the appropriate type, including


manufacturer model & class of respirator being used for this job.

E A R S /H E A R IN G

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

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