APPENDIX “12” SIGN DESIGN &FABRICATION, INC.

PERSONAL PROTECTIVE EQUIPMENT CERTIFICATION OF HAZARD ASSESSMENT

I certify that a hazard assessment of the workplace was performed at our facility located at 35 Breakstone Drive, Dahlonega, Ga. This assessment consisted of a review of prior injury and illness records and a walk-through inspection of all work areas. The purpose of this assessment was to identify sources of hazards to Employee(s) that are present, or are likely to be present, in the workplace which necessitate the use of personal protective equipment (PPE).

Workplace Evaluated:

(Insert area of the facility and a listing of all departments or areas of the facility that were inspected.)

Person Certifying Hazard Assessment:

Name: ___________________________________ Title: ______________________ Date(s) of Hazard Assessment: ____________________

EMPLOYEE(S) NOTIFIED PERSONAL PROTECTION REQ.

EMPLOYEE SIGNATURE: _________________________ DATE: __/__/____

EMPLOYEE SIGNATURE: _________________________DATE: __/__/____

Attachments: Hazard Assessment Forms

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