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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:__________________________