• Instructions
    -------------------------
    1. Answer "Safe", "At Risk", "N/A" for each of the hazards below
    2. If "At Risk", follow the questions to identify the likelihood of occurrence, severity and risk rating
    3. Include any notes and photos by clicking on the paperclip icon and then "Add Image"
    4. Answer the relevant control questions
    5. Complete the form by providing the relevant signatures

Confined Space

  • Confined Space

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Confined Space permit received

  • Enter description of control measures

Working at Height

  • Working at Height

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Working at height permit received

  • Height safety harness worn

  • Enter description of control measures

Restricted Access

  • Restricted Access

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Electricity

  • Electricity

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Compressed Air

  • Compressed Air

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Uneven/slippery Surfaces

  • Uneven/slippery Surfaces

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Hazardous Gases

  • Hazardous Gases

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Asbestos

  • Asbestos

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Vehicular movement

  • Vehicular movement

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Dust & Airborne particle's

  • Dust & Airborne particle's

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Working over/near water

  • Working over/near water

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Overhead hazards

  • Overhead hazards

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Manual handling

  • Manual handling

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Fire / Explosion

  • Fire / Explosion

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Noise

  • Noise

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

UV

  • UV

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Buried/Covered services

  • Buried/Covered services

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Lone worker

  • Lone worker

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Spills / Pollution

  • Spills / Pollution

  • Likelihood of occurrence

  • Severity

  • Risk rating

  • Enter description of control measures

Completion

  • Observations and recommendations

  • Work completed

  • Equipment is safe & fit to operate

  • Customer representative

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.