Workplace Hazard Assessment Form for Laboratories
For identification of needed Personal Protective Equipment (PPE)
Principle Investigator
Department
Building
Lab Room Number
Lab Functions/Activities
Hazard Assessment and Personal Protective Equipment (PPE)
Check for hazards present, describe hazards, check if PPE is required (eye/face, head, hand, clothing, foot/leg, or other), and describe specific PPE required.
Impact (e.g. flying objects, sand, dirt, dust, particulate, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Impact Hazards
Do impact hazards prevent working alone?
Please Select
Yes
No
Cuts/Penetration (e.g. cuts, punctures, lacerations, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Cuts/Penetration Hazards
Do cut/penetration hazards prevent working alone?
Please Select
Yes
No
Pinch/Crush/Roll Over (e.g., moving machine parts, falling/rolling heavy equipment, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Pinch/Crush/Roll Over Hazards
Do pinch/crush/roll over hazards prevent working alone?
Please Select
Yes
No
Chemical (e.g. pouring, mixing, splash hazards, washing/cleaning, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Specific Chemical Hazards
Chemical Hazard
Description of Chemical Hazard
Flammable
Toxic
Corrosive
Reactive
Asphyxiant
Other
Describe Chemical Hazards
Do chemical hazards prevent working alone?
Please Select
Yes
No
Biological (e.g. infectious materials, human or animal tissue, blood or body fluids, biological toxins, etc.) - Refer to BAUR and/or PPE discussed during Biosafety audit or the PPE listed in your MUA to complete this section
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Biological Hazards
Do biological hazards prevent working alone?
Please Select
Yes
No
Thermal (Hot/Cold) (e.g. torching, hot sparks, working with cryogenic gases, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Thermal Hazards
Do thermal hazards prevent working alone?
Please Select
Yes
No
Electrical (e.g. exposed electrical conductors, energized parts, electrical switch gear, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Electrical Hazards
Do electrical hazards prevent working alone?
Please Select
Yes
No
Harmful Dust/Mists/Fumes/Vapor (e.g., grinding, drilling, sanding, welding, soldering, working with silica dust, animal bedding, allergens, nanomaterials, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Respiratory
(Contact EH&S
for direction)
Other
Describe Dust/Mists/Fumes/Vapor Hazards
Do dust/mists/fumes/vapor hazards prevent working alone?
Please Select
Yes
No
Light (Optical) Radiation (e.g. laser, UV light, welding, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Other
Describe Light (Optical) Hazards
Do light hazards prevent working alone?
Please Select
Yes
No
Ionizing Radiation (e.g., radioisotopes, X-rays, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Eye/Face
Hand
Head
Clothing
Foot/Leg
Other
Describe Ionizing Radiation Hazards
Do ionizing radiation hazards prevent working alone?
Please Select
Yes
No
Noise (e.g. continuous noise, impact noise, intermittent noise, etc.)
Personal
Protective
Equipment
(PPE)
Required
Describe Specific PPE Required
Hearing
(Contact EH&S
for direction)
Describe Noise Hazards
Do noise hazards prevent working alone?
Please Select
Yes
No
Assessment Completed By:
Title
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: