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Attachment 1Workplace Hazard Assesment Certification Form |
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| Instructions: Complete form using Personal Protective Equipment Hazard Assessment Guidelines. Completed form is to be retained for departmental records. |
| Supervisor conducting the hazard assessment: | Date of hazard assessment: |
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| Work Activity Assessed | Location of Assessment (Bldng / Rm) |
Hazard(s) Identified | PPE Selected (Make & Model #) |
|---|---|---|---|
| ___________________________________ ___________________________________ ___________________________________ |
___________________________________ ___________________________________ ___________________________________ |
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| ___________________________________ ___________________________________ ___________________________________ |
___________________________________ ___________________________________ ___________________________________ |
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| ___________________________________ ___________________________________ ___________________________________ |
___________________________________ ___________________________________ ___________________________________ |
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| ___________________________________ ___________________________________ ___________________________________ |
___________________________________ ___________________________________ ___________________________________ |
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| ___________________________________ ___________________________________ ___________________________________ |
___________________________________ ___________________________________ ___________________________________ |
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| ___________________________________ ___________________________________ ___________________________________ |
___________________________________ ___________________________________ ___________________________________ |
| I, _________________________, certify that the assessment
of the identified woek activities has been performed. Date:
Signature |
