Title Page

  • Take5.jpg
  • Date of the Assessment

  • Prepared by

  • Line

  • Department

  • Equipment


HAZARD CHECKLIST Look Close, Look Wide, Look Above, Look Below Have I considered / Am I at risk from:

People / Ergonomic Hazards

  • Awkward posture

  • Repetitive movements

  • Manual Handling

  • Heavy lifting, pushing, pulling

  • Difficult access to workspace

  • Others working around me (above and below)

  • Other

Environmental Hazards

  • Poor housekeeping

  • Poor visibility

  • Wet, slippery and unstable surfaces

  • Noise and vibrations

  • Flying particles

  • Heat and extreme temperatures

  • Exhaust fumes and gases

  • Working in a confined space

  • Poor weather

  • Other

Mechanical Hazards

  • Mobile equipment

  • Rolling machinery

  • Rotating components

  • Pinch points

  • Sharp or pointed parts

  • Insufficient strength

  • Other

Gravitational Hazards

  • Working at height

  • Potential falling objects

  • Heavy equipment or tools

  • Suspended loads

  • Other

Other Hazards

  • Stored energy

  • Chemical

  • Electrical

  • Biological

  • Radiation

  • Dust

  • Fire

  • Pressure release

  • Other

1: Stop and Think

  • Do I have the required skills and knowledge?

  • Does a procedure exist

  • Do I understand the steps required to do the job?

  • Are the tools and equipment available and in good order?

  • Do I have the correct PPE?

  • Do I have the required permit or authority to do this work?

  • Have I got a plan in mind?

2: Look for the Hazards

  • Will I be operating equipment with guards removed?

  • Am I or others at risk from the operation of mobile equipment or machinery?

  • Is there a manual handling risk?

  • Will I be working at height or in a confined space?

3: Assess the Risk

  • Severity_Potential.jpg
  • What is Severity Potential?

4: Make the Changes

  • Have I controlled all hazards so I will be safe? **Include a picture**

5: Do the Job Safely

  • I can do the job Safely.

  • Supervisor Sign Off

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.