Title Page
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DATE OF ASSESSMENT
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TIME OF ASSESSMENT
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ADDRESS OF SITE ASSESSED
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JOB NUMBER OF SITE ASSESSED
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WORKER COMPLETING ASSESSMENT
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Photo of Front of Lot
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1. WEATHER CONDITIONS ( Is the weather a hazard? What is the possibility of weather being a hazard? )
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COMMENTS
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What is the temperature today?
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2. OVERHEAD DANGERS ( Are there any dangers from material or other workers on site? )
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COMMENTS
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3. EXCAVATIONS ( Are there any open excavations on site to be aware of? )
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COMMENTS
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4. PPE ( Do you require any PPE due to cutting material, overhead dangers or from other workers? Are safety glasses required due to cutting or sawing? )
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COMMENTS
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5. OTHER WORKERS ( Are there other workers on site and is the work they are doing hazardous? )
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COMMENTS
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6. RAMPS/STAIRS ( Is there a ramp or stairs going onto the site? Is it in good condition? Are there stairs going into the basement?)
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COMMENTS
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7. FLOOR OPENINGS ( Are there any openings in the floor that could be dangerous? )
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COMMENTS
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8. GUARDRAILS ( Are the guardrails in place on all stairs on site? )
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COMMENTS
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9. LIFTING ( Are you lifting material that could result in a strain? Should there be 2 people moving the item? )
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COMMENTS
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10. HAZARDOUS CHEMICALS ( Are you using chemicals and do you have an MSDS sheet for it? )
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COMMENTS
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11. SITE CLEANLINESS ( Is the worksite clean? Is there anything that will cause an injury to you in way of debris etc? )
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COMMENTS
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Add media
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Was Corrective Action Required for any task 1-11? If Yes please include corrective action notes below.
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What Corrective Action Was Taken?
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Add media
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Employee Signature Completing Form
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Other Worker at time of Assessment
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Other Worker at time of Assessment
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Other Worker at time of Assessment
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Other Worker at time of Assessment
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Other Worker at time of Assessment
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Other Worker at time of Assessment
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Safety Officer Review
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Date Safety Officer Reviewed
