2.2 PER-JOB HAZARD INSPECTION (FORM)

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Job Site Name:

• Location / Address:

• Date / Time:

• Assessment Conducted By:

• (1)

• (2)

• Position:

• (1)

• (2)

• Work To Be Done:

• Crew Size:

Severity Rating: (1= Imminent Danger) (2= Serious) (3= Minor) (4= Not Applicable (N/A))

• Step 1:

• IDENTIFIED HAZARDS
  (ACTIVITIES & CONDITIONS)

• ITEM# 1 HOUSEKEEPING

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 2 MATERIAL STORAGE

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 3 WAST DISPOSAL

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 4 LIGHTING

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 5 VENTILATION

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 6 EXTREME TEMPERATURES

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 7 FLAMMABLES-FIRE/EXPLOSION)

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 8 CHEMICALS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 9 HAZARDOUS MATERIALS/WHMIS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 10 HIGH RISK POSITIONING

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 11 ELECTRICAL HAZARDS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 12 OVERHEAD HAZARDS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 13 UNDERGROUND HAZARDS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 14 RESTRICTED ACCESS/EGRESS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 15 LADDERS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 16 WORK AT HIGHTS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 17 SCAFFOLDS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 18 MAJOR LIFTS (HOISTING)

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 19 VEHICLES

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 20 MOBILE EQUIPMENT

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 21 HIGHT TRAFFIC

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 22 POWER TOOLS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 23 COMMUNICATION/WORKING ALONE

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 24 FATIGUE

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 25 GUARDRAILS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 26 GRINDING

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 27 CUTTING

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 28 SIGNALS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 29 FLOOR/ROOF/WALL OPENINGS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 30 POWER PLATFORMS

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 31 FALL ARREST

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• ITEM# 32 FIRE PREVENTION

• SEVERITY / PROBABILITY

• SAFETY HAZARD & LOCATION

• STEP 2:

HAZARD ASSESSMENT CORRECTIVE ACTION

• Job Site Name:

• Date/Time:

• Assessment Location:

• Area Covered:

• PJHA Conducted by:

• (1)

• (2)

• Position

• (1)

• (2)

Probability Rating: (A. Probable-likely to occur immediately or soon) (B. Reasonably Probable-like to occur eventually) (C. Remote-could occur at some point) (D. Extremely remote-unlikely to occur)

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• ITEM#

• PRIORITY

• RECOMMENDED ACTION

• BY WHOM

• ACTION TAKEN

• DATE/TIME

• COPIES TO: (FOR ACTION):

• (FOR INFORMATION)

• MANAGER'S SIGNATURE: DATE:

  Sign