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NOTE: Must be printed on 8.5 x 14 paper, landscape orientation
VCU PERSONAL PROTECTIVE EQUIPMENT ASSESSMENT
LOCATION (Building – Floor – Wing):
UNIT/DEPARTMENT:
SUPERVISOR / MANAGER:
ASSESSMENT CONDUCTED BY (Name/Title):
DATE:
LIST JOB TITLES IN THIS UNIT/DEPARTMENT REQUIRING PERSONAL PROTECTIVE EQUIPMENT (PPE). If none, write “NONE” on Line #1.
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
WORKPLACE HAZARDS:
A. Liquid Chemicals
B. Acids or Caustics
NO.
JOB
TITLE
C. Hazardous Gases or Vapors
D. Radiation Exposure
TASKS
G. Extreme Temperatures/Thermal Burns
H. Cuts, Scrapes, Punctures
HAZARDS
LIST JOB TASKS PERFORMED
(#1-10
above)
E. Electricity Exposure
F. Blood and Body Fluid Exposure
I. Extreme Light or Laser
J. Other:
DENOTE PERSONAL PROTECTIVE EQUIPMENT NEEDED
FACE/EYE
HEAD
HAND
FOOT
HEARING
TORSO
RESPIRATORY
HOOD
OTHER
IDENTIFY
(Type)
(Type)
(Type)
(Type)
(Type)
(Type)
(Type)
(Type)
(List)
(By Letter)
SAFETY
GLASSES
HARD HATS
GLOVES
rubber,
latex,
chemical
resistant
SAFETY
SHOES
EAR PLUGS
APRON
lead, rubber
Lab Coat
FLUID
RESISTANT
CLOTHING
RESPIRATOR
Chemical
or
Biological
POTENTIAL
HAZARDS
FOR EACH
TASK
GOGGLES
HEAD/HAIR
COVERINGS
FACE SHIELD
SHOE
COVERS
HEAD
PHONES
MASK
The Unit/Department or Administrative Unit is also responsible for training. The employee must be trained to know when the PPE is necessary; what PPE is necessary; how to properly don, doff, adjust, and wear the PPE; the limitations of the PPE; and the proper care, maintenance,
useful life, and disposal of the PPE. The employee must demonstrate an understanding of the training before being allowed to perform work requiring the use of the PPE. All training must be documented (name of employee trained, date, subject, person who performed training).
Retraining is required if changes occur in the workplace rendering previous training obsolete; if there are changes in the PPE to be used; or if the employee shows indications that he/she has not retained the requisite understanding or skill in order to properly use the assigned PPE.
Employee Name:___________________________
Date:________________________
Employee Signature:_________________________
Supervisor Signature:__________________________
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