Certification of Hazard Assessment - 29 CFR 1910.132(d)(2)
Workplace evaluated: ____________________________
Tasks or jobs: _________________________________
Head hazards
(check all that apply)q Impact q Penetrationq Compression (roll-over)q Chemicalq Heatq Harmful dustq Light (optical) radiationq Electricalq Noiseq Ergonomicq Other ___________________ |
Describe specific hazards |
Engineering or administrative controls
Identify type of PPE required |
Eye and face
hazards (check all that apply)q Impact q Penetrationq Compression (roll-over)q Chemicalq Heatq Harmful dustq Light (optical) radiationq Electricalq Noiseq Ergonomicq Other ___________________ |
Describe specific hazards |
Engineering or administrative controls
Identify type of PPE required |
Respiratory system
hazards (check all that apply)q Impact q Penetrationq Compression (roll-over)q Chemicalq Heatq Harmful dustq Light (optical) radiationq Electricalq Noiseq Ergonomicq Other ___________________ |
Describe specific hazards |
Engineering or administrative controls
Identify type of PPE required |
Hand hazards
(check all that apply)q Impact q Penetrationq Compression (roll-over)q Chemicalq Heatq Harmful dustq Light (optical) radiationq Electricalq Noiseq Ergonomicq Other ___________________ |
Describe specific hazards |
Engineering or administrative controls
Identify type of PPE required |
Body
hazards (check all that apply)q Impact q Penetrationq Compression (roll-over)q Chemicalq Heatq Harmful dustq Light (optical) radiationq Electricalq Noiseq Ergonomicq Other ___________________ |
Describe specific hazards |
Engineering or administrative controls
Identify type of PPE required |
Foot
hazards (check all that apply)q Impact q Penetrationq Compression (roll-over)q Chemicalq Heatq Harmful dustq Light (optical) radiationq Electricalq Noiseq Ergonomicq Other ___________________ |
Describe specific hazards |
Engineering or administrative controls
Identify type of PPE required |
I, _________________________________________________(name & title), certify that the evaluation of the identified work area was performed on _______________(date).
Signature: _______________________________________________
Form by Cynthia Duffield, CIH, CSP, CQE - January 19, 1999