PPE Inspection Checklist
General requirements and practices for employees using PPE.
1/9
Title Page
* Audit Title Text answer
* Community Select one
[ ] City of Kaukauna
[ ] Kaukauna Utilities
[ ] Menasha Utilities
[ ] Two Rivers
[ ] City of Sturgeon Bay
[ ] Sturgeon Bay Utilities
[ ] New Holstein
* Department Select one
[ ] Cemetary
[ ] City Hall
[ ] DPW
[ ] Finance Dept.
[ ] Fire Dept.
[ ] Police Dept.
[ ] Library
[ ] Parks Dept.
[ ] Recreation Dept.
2/9
[ ] Water Dept.
[ ] Other: ____________________
* Conducted on Date/time
Enter Date and Time:
/ /
: AM / PM
* Prepared by Text answer
* Location Text answer
3/9
Audit
Hand Protection - Gloves
Are gloves being used by employees where hand hazards exist? Select one
[ ] Yes
[ ] No
[ ] N/A
Are gloves worn by employees suitable for hand hazards? Select one
[ ] Yes
[ ] No
[ ] N/A
Are gloves free of damage or defects, and in clean/sanitary Select one
condition?
[ ] Yes
[ ] No
[ ] N/A
Are gloves stored properly when not in use? Select one
[ ] Yes
[ ] No
[ ] N/A
Are gloves being properly disposed of when damaged or defective? Select one
[ ] Yes
[ ] No
[ ] N/A
Protective Clothing
4/9
Is high visibility safety vest / shirt / jacket being worn? Select one
[ ] Yes
[ ] No
[ ] N/A
Is protective clothing worn suitable for existing hazards? Select one
[ ] Yes
[ ] No
[ ] N/A
Is protective clothing free of damage or defects? Select one
[ ] Yes
[ ] No
[ ] N/A
Does protective clothing fit properly? Select one
[ ] Yes
[ ] No
[ ] N/A
Protective Footwear
Is protective footwear being used by employees where foot hazards Select one
exist?
[ ] Yes
[ ] No
[ ] N/A
Is protective footwear worn by employees suitable for hazard? Select one
[ ] Yes
[ ] No
[ ] N/A
5/9
Is protective footwear properly fitted? Select one
[ ] Yes
[ ] No
[ ] N/A
Is protective footwear free of damage or defects? Select one
[ ] Yes
[ ] No
[ ] N/A
Head Protection - Hard Hats
Are hard hats being worn where head hazards exist? Select one
[ ] Yes
[ ] No
[ ] N/A
Are hard hats properly fitted and worn properly? Select one
[ ] Yes
[ ] No
[ ] N/A
Are hard hats free of damage or defects? (i.e. cracks, UV damage, Select one
chips, etc.)
[ ] Yes
[ ] No
[ ] N/A
Are the hard hat suspension systems in good condition? Select one
[ ] Yes
[ ] No
6/9
[ ] N/A
Hearing Protection
Is hearing protection being worn where noise hazards are above 90 Select one
dB?
[ ] Yes
[ ] No
[ ] N/A
Is hearing protection being used protect against present noise Select one
hazards?
[ ] Yes
[ ] No
[ ] N/A
Is hearing protection being worn properly? Select one
[ ] Yes
[ ] No
[ ] N/A
Is hearing protection free of damage or defects? Select one
[ ] Yes
[ ] No
[ ] N/A
Face/Eye Protection
Is face/eye protection being worn by employees where face/eye Select one
hazards exist?
[ ] Yes
[ ] No
[ ] N/A
7/9
Is face/eye protection suitable for hazards? Select one
[ ] Yes
[ ] No
[ ] N/A
Is face/eye protection properly fitted and worn? Select one
[ ] Yes
[ ] No
[ ] N/A
Is face/eye protection free of damage or defects? Select one
[ ] Yes
[ ] No
[ ] N/A
Respiratory Protection - Respirators
Are respirators being used where respiratory hazards exist? Select one
[ ] Yes
[ ] No
[ ] N/A
Are respirators being used suitable for hazards present? Select one
[ ] Yes
[ ] No
[ ] N/A
Are respirators fitted and worn properly? Select one
[ ] Yes
[ ] No
[ ] N/A
8/9
Are respirators being stored properly when not in use? Select one
[ ] Yes
[ ] No
[ ] N/A
Additional Comments
Additional safety concerns Instruction
9/9