ࡱ>  bjbjVV k<<-< $   PY d4 M*c*c*c*R+f3,7:z9R+R+99c*c*XXX9N c*c*X9XX*[ c*y JDN WR40dbVNN V V 99X99999X999d9999V999999999 :  ANNUAL PPE ASSESSMENT & TRAINING FORM DIRECTIONS The Principal Investigator/Manager/Supervisor shall assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of Personal Protective Equipment (PPE). If such hazards are present, or likely to be present, the employer shall: Select the types of PPE that will protect the affected employee from the hazards identified in the hazard assessment Ensure that each affected employee uses the provided PPE correctly The Principal Investigator/Manager/Supervisor shall verify that the required workplace hazard assessment has been performed using the Annual PPE Assessment and Training form that identifies the workplace evaluated; the person certifying that the evaluation has been performed and the date of the assessment. Personal Protective Equipment includes protective equipment for eyes, face, head, and extremities, protective clothing, respiratory devices, and protective shields and barriers. PPE shall be provided, used, and maintained in a sanitary and reliable condition wherever it is necessary by reason of hazards of processes or environment, chemical hazards, radiological hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation or physical contact. Principle Investigator/Manager/Supervisor:  FORMTEXT      Date:  FORMTEXT      Department:  FORMTEXT     Building:  FORMTEXT     Room Number:  FORMTEXT     Where will you work? FORMCHECKBOX  Clinical Environment  FORMCHECKBOX  Research Laboratory Environment  FORMCHECKBOX  Administrative/Academic Environment FORMCHECKBOX  Animal Research Program (ARP)  FORMCHECKBOX  Engineering, Support Services  FORMCHECKBOX  Other: ____________________________Need to update your PeopleSoft Hazard Assessment? Visit this site: HYPERLINK "http://www.hrfin.wfubmc.edu:8001/psp/hepro/EMPLOYEE/HRMS/"http://www.hrfin.wfubmc.edu:8001/psp/hepro/EMPLOYEE/HRMS/Positions being assessed:  FORMTEXT      EYE HAZARDS may include the following: working with animals, chemicals, chipping, sanding, grinding, welding, metal and wood working, radioactive materials, biological materials, laboratory work/research. Check the box for each hazard:Description of hazard(s):Controls in place:Identify required PPE:Chemical ExposureYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Work in fume hoods FORMCHECKBOX Safety glassesHigh Heat/ColdYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Enclosure/guarding FORMCHECKBOX Safety gogglesDust or Flying DebrisYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Shielding (bystanders) FORMCHECKBOX Face shieldImpactYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Safe Work Practices FORMCHECKBOX Welding helmetUV Light/RadiationYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Dust collection system FORMCHECKBOX Cutting gogglesWork with AnimalsYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT      FOOT HAZARDS may include the following: exposure to chemicals, welding, cutting, materials handling, demolition, renovation, electrical work, flammable materials, etc.Check the box for each hazard:Description of hazard(s):Controls in place:Identify required PPE:Chemical ExposureYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Substitution FORMCHECKBOX Work bootsHigh Heat/ColdYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Mechanical device used FORMCHECKBOX Steel-toed shoes/bootsImpact/CompressionYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Housekeeping FORMCHECKBOX Slip-resistant shoesPunctureYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Isolation/grounding FORMCHECKBOX Puncture-resistant shoesExplosive/Flam. atmos.Yes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Safe Work Practices FORMCHECKBOX Non-conductiveSlippery/Wet SurfacesYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Appropriate clothing FORMCHECKBOX Metatarsal protectionElectricalYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Shin guardsOther:Yes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT      HAND HAZARDS may include the following: work with animals, chemicals, abrasion/cut hazards during demolition and renovation, lab research, animal areas, radioactive and biological materials. ADDITIONAL TRAINING REQUIRED VIA EH&S FOR BLOODBORNE PATHOGENS and Herpes B. CONTACT AMY NELSON AT 6-6084.Check the box for each hazard:Description of hazard(s):Controls in place:Identify required PPE:Chemical ExposureYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Substitution FORMCHECKBOX Chemical-resistant glovesHigh Heat or ColdYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX De-energization FORMCHECKBOX Thermal-protective glovesCuts/Abrasion/PunctureYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Elimination FORMCHECKBOX Cut-resistant glovesWork with AnimalsYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Avoidance FORMCHECKBOX Leather glovesElectrical ShockYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Voltage-rated Class: FORMTEXT      RadiationYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Nitrile/Latex exam glovesVibration/gripYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Anti-vibration glovesWorking with AnimalsYes  FORMCHECKBOX  FORMTEXT      Bloodborne Pathogens Yes  FORMCHECKBOX  FORMTEXT      BODY/TORSO HAZARDS may include the following: chemical/hazardous material exposure, abrasive blasting, welding, cutting, brazing, chipping, sanding, grinding, high heat/cold, radiological or biological work.Check the box for each hazard:Description of hazard(s):Controls in place:Identify required PPE:Chemical ExposureYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Reduce time exposed FORMCHECKBOX Lab coatExtreme Heat/ColdYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Guards/barriers FORMCHECKBOX Apron: FORMTEXT      RadiationYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Substitution FORMCHECKBOX Flame-retardantImpactYes  FORMCHECKBOX  FORMTEXT       FORMCHEC  '()*45ObñÍ|m[I8'8 h1hkCJOJQJ^JaJ h1hqCJOJQJ^JaJ#h1hq6CJOJQJ^JaJ#h1h045CJOJQJ^JaJh5CJOJQJ^JaJ h1h*CJOJQJ^JaJ#h1hD5CJOJQJ^JaJ#h1h045CJOJQJ^JaJ#h1h5CJOJQJ^JaJ#h1hq5CJOJQJ^JaJh..h..5CJOJQJaJ3jhJhJ5CJOJQJUaJmHnHu()*5M N   < = i j D $Ifgd>gdq [$\$^gdk & F%[$\$gdk [$\$gdk 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ADDITIONAL TRAINING REQUIRED VIA EH&S. CONTACT CHRIS KOLBASH AT 6-1120Check the box for each hazard:Description of hazard(s):Controls in place:Based upon EHS evaluation, the following PPE is required:Noise hazardYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Noise reduction  FORMCHECKBOX Reduced exposure FORMCHECKBOX Ear plugs  FORMCHECKBOX Ear muffsUltrasonicsYes  FORMCHECKBOX  FORMTEXT      RESPIRATORY HAZARDS may include the following: using certain chemicals outside a fume hood, applying paints/chemicals in confined spaces, welding certain metals, disturbing asbestos or mold. ADDITIONAL TRAINING REQUIRED VIA EH&S. CONTACT CHRIS KOLBASH AT 6-1120Check the box for each hazard:Description of hazard(s):Controls in place:Based upon EHS evaluation, the following PPE is required:ChemicalsYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Fume hood FORMCHECKBOX Dust mask/N95 RespiratorParticulates Yes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Local exhaust ventilation FORMCHECKBOX Half-faceConfined space workYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Increase air flow  FORMCHECKBOX Full-faceWelding/cutting fumesYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Filtration FORMCHECKBOX PAPRWork with AnimalsYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Work outside FORMCHECKBOX SCBAOtherYes  FORMCHECKBOX  FORMTEXT      FALL HAZARDS Work on a surface with an unprotected side or edge that is 4 feet or more above a lower levelCheck the box for each hazard:Description of hazard(s):Controls in place:Identify required PPE:Fall hazardYes  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Guardrail  FORMCHECKBOX Safe ladder practices FORMCHECKBOX Full-body harness TRAINING The Principal Investigator/Manager/Supervisor shall provide annual training to each employee who is required to use PPE. Each employee shall be trained to know at least the following: When PPE is necessary What PPE is necessary; How to properly don, doff, adjust, and wear PPE; The limitations of the PPE; and, The proper care, maintenance, useful life and disposal of the PPE. The Principal Investigator/Manager/Supervisor shall verify that each affected employee has received and understood the required training through the use of Certification of Personal Protective Equipment (PPE) Training Form. CERTIFICATION OF PERSONAL PROTECTIVE EQUIPMENT (PPE) TRAININGDate:  FORMTEXT      Department:  FORMTEXT      Building:  FORMTEXT      Room:  FORMTEXT      Principle Investigator/Manager/Supervisor:  FORMTEXT      Training Conducted By:  FORMTEXT      SUBJECTS COVEREDReview chemical, biological and radiological hazards in laboratoryReview when PPE is necessaryReview what PPE is necessaryReview how to properly don, doff, adjust, and wear PPEReview the limitations of the PPEReview the proper care, maintenance, useful life and disposal of the PPENAMESIGNATUREDATE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Once form is completed, send a copy to EH&S     Revised Sep.2011  PAGE \* MERGEFORMAT 1 .0LNPdf.0L͹Ͳ͊͞s_'jhMhlOJQJU^J,jhMhAUOJQJU^JmHnHu'jhMhlOJQJU^J'jhMhlOJQJU^J 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