Hazard Assessment Date *Job Project Address *Job Description *Hazards Present or About to be CreatedHearing Hazard? *YesNoSelect Equipment *Ear Plugs?Ear Muffs?Eye Hazard? *YesNoSelect Equipment *Safety Glasses?Face Shield?Breathing Hazard? *YesNoSelect Equipment *Dust Mask?Respirator?Cut Hazard? *YesNoDo you have the right kind of gloves? *YesNoHazard to Head? *YesNoDo you have your hardhat? *YesNoHazard to Feet? *YesNoDo you have your steeltoe/carbon fiber toe boots? *YesNoPinch/Crush Hazard? *YesNoUsing a Ladder? *YesNoDoes the job require you to work at heights (above 3m)? *YesNoDoes everyone who’s wearing fall protection have in class fall protection training? *YesNoIs there a completed fall protection plan on site that has been signed off by everyone working at heights? *YesNoIs everyone who’s fall protection trained wearing a fall protection harness? *YesNoIs the fall protection lanyard, and anchor point being used as per manufacturers' directions? *YesNoRisk of Fire? *YesNoDid you take precautions to prevent fire? *YesNoSlip or Trip Hazard? *YesNoLow Lighting? *YesNoChemicals? *YesNoDo you have the Safety Data Sheet (SDS)? *YesNoWeather Hazard?YesNoPlease specify weather hazard. *Vehicle Traffic Hazard? *YesNoAre you wearing high vis clothing? *YesNoRepetitive Motion? *YesNoPowertools/Powered Equipment? *YesNoTool inspected before use? *YesNoCompressed Gas Cylinders? *YesNoAre cylinders secured from falling over? *YesNoAny Moving Parts? *YesNoHas LOTO been performed? *YesNoIf NOT, why? *Electrical? *YesNoHas LOTO been performed? *YesNoIf NOT, why? *Hydraulics? *YesNoHas LOTO been performed? *YesNoIf NOT, why? *Pressured Lines? *YesNoHas LOTO been performed? *YesNoIf NOT, why? *Mobile Equipment Use? *YesNoHas the equipment had its annual inspection as per manufacturer? *YesNoIs it being operated by a trained and certified operator? *YesNoExcavations? *YesNoIs there safe access in and out? *YesNoAre the banks stepped or 45'D above 4'? *YesNoAdditional Hazards? *YesNoPlease specify *Additional Hazards? *YesNoPlease specify *Hazard RatingHow serious is the hazard without any control? [1 = Imminent Danger; 2 = Serious; 3 = Minor; 4 = OK]What are the chances something would happen without any controls in place? [A = Probable; B = Reasonable Probable; C = Remote; D = Extremely Remote]1Item #Rating: 1-5 / A-DCorrective actions to address hazards2Item #Rating: 1-5 / A-DCorrective actions to address hazards3Item #Rating: 1-5 / A-DCorrective actions to address hazards4Item #Rating: 1-5 / A-DCorrective actions to address hazards5Item #Rating: 1-5 / A-DCorrective actions to address hazards6Item #Rating: 1-5 / A-DCorrective actions to address hazardsSIGNATURES1Print Name *Sign Name *All my PPE have been inspected for damage today before use *Date *Email Address *Consent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.2Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.3Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.4Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.5Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.6Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.7Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.8Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.9Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.10Print NameSign NameAll my PPE have been inspected for damage today before useDateConsent/Signature *BY SIGNING MY NAME/INPUTTING MY INITIALS ABOVE, I AM SIGNING THAT I HAVE READ AND COMPLETED THIS ASSESSMENT AND THAT I UNDERSTAND THE HAZARDS THAT HAVE BEEN IDENTIFIED FOR THE WORK ABOUT TO BE PERFORMED AND THE HAZARDS THAT ALREADY EXIST IN MY WORK AREA. BY SIGNING MY NAME/INPUTTING MY INITIALS BELOW, I ALSO UNDERSTAND AND AGREE TO FOLLOW THE CONTROLS THAT HAVE BEEN PUT IN PLACE TO PROTECT ME FROM THE IDENTIFIED HAZARDS.Submit
