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Hazard Assessment
Workers Present
John Smith
Anna Bell
Bob (Just Bob)
Other worker
Location of Work
Muster Point
Work To Be Done
Current Tasks
Enviromental Hazards
Dust / Mist Fumes
Noise in area
Extreme Temperatures
Spill potential
Waste
Other workers in area
Weather conditions
Ergonomic Hazards
Awkward body position
Over extension
Twisting / Repetitive Motion
Working in a tight area
Lift too heavy / Awkward to lift
Hands not in line of sight
Working overhead
Access / Egress Hazards
Ladders (tied off)
Slips / Trips / Falls
Evacuation
Overhead Hazards
Hole coverings
Tie-off & anchor points
Falling objects
Power lines
Rigging / Hoisting Hazards
Hoisting or moving loads
Tools & Sling
Others working nearby
Personal Hazards
SOP not available for task
Confusing instructions
No training for task
1st time performing the task
Electrical Hazards
Light levels too low
Working near energized equipment
Electrical cords/tool condition
Static & Grounding (bonding)
Transportation Hazards
Narrow/logging road
Heavy traffic
Vehicle stability (high/wide)
Limited/poor visibility
Obstruction on roadway
Road conditions
Flammable substances
Additional Hazard 1
Additional Mitigation 1
Additional Hazard 2
Additional Mitigation 2
Additional Hazard 3
Additional Mitigation 3
Warning Ribbon Required?
Yes
No
If Ribbon Required, Explain Why
Working Alone?
Yes
No
PPE Inspected?
Yes
No
Is there Hazards Remaining?
Yes
No
If Yes, Explain What
Are Workers Fit for Duty?
Yes
No
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