Title Page
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Thankyou for filling out your daily jobsite field level hazard assessment. Please answer all questions truthfully. You have the right to refuse unsafe work.
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Client
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What is the task / tasks being performed?
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Location
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Conducted on
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Prepared by
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FLHA #
Site Conditions
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Safe entry / exit
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Excavations (holes)
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Slip or trip hazards
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Cranes, powerlines, or other overhead hazards
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Handrails, guardrails, balconies & floor openings
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Noise
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Lighting / visibility
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Housekeeping / waste
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Material storage / flamables
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Heaters
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Electrical outlets / panels
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Ventilation / hazardous fumes
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Scheduling
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Are you working alone?
- I'm here with my team
- There are other people on site that know I'm here
- I'm working alone
- I'm working alone and no one knows where I am
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Who is checking in on you?
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Workers on site
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Enter your teamates full names
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Stop what you are doing and contact a supervisor immediately
Emergency Perparedness
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Is emergency procedure posted and current?
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Are emergency first aid kits fully stocked, visible and accessible?
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Are workers aware of what to do in an emergency?
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Are fire extinguishers inspected, tagged with current months inspection and in good working order?
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Is there need for a work at heights or confined space rescue plan?
Tools, Equipment & PPE (Personal Protective Equipment)
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Ladders, planks & benches
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Scaffolding
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Stilts
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Hand tools
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Power tools
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Cords
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PPE required on this site
- Steel toe boots
- Hard hat
- High vis vest
- Safety glasses / face shield
- Face mask
- Hearing protection
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Masks / respirators required?
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Clothing
Documentation
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Training / orientation
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Evacuation plan reviewed
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Is there a first aider on site?
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Enter name of the first aider
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First aid kit location
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Muster point location
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Safety handbook
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GHS (Globally Harmonized System of Classification and Labeling of Chemicals)
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SDS (Safety Data Sheets)
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ERN (Emergency Response Numbers)
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Is a fall arrest plan required?
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Identify any other hazards on the site
Click Add to sign
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Enter your full name and sign