Title Page

  • Site Name

  • Date

  • Prepared by

  • Job Location
  • Service Case Number

Job Site Hazards

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Tasks

  • Steps

  • Potential Hazards

  • Steps to Eliminate/Control

  • Lockout - Tagout Required?

  • Safety Barrier Required?

  • Is the worker working alone?

  • What additional control measures taken for solo work?

  • Permit(s) Required?

  • What control measures taken?

  • Are instruments calibrated?

  • Write Equipment ID # and Calibration Date

Job Hazards

Electrical Hazards

  • Testing of Energized Equipment

  • Energized Device - DC

  • DC Voltage

  • Energized Device - AC

  • AC Voltage

  • Arc Flash Risks

  • Proper Tools NOT Available

Work Area Hazards

  • Critical Lifting

  • No Delimitation Barricades / Signs

  • Other Workers In Area (Conflicting Work)

  • Simultaneous Activity

  • Working Alone (Attach Rescue Plan)

Site Specific Conditions

  • Holes, Ditches, Trenches

  • Low Obstructions (Overhead)

  • Falling Item / Material

  • Overhead Power

  • Potential Gas

  • Fire / Explosion Risk

  • Lighting Levels Too Low

Working From Heights

  • Height of Work

  • Aerial Lift / Man Basket Required

  • Scaffold Required

  • Ladders Required

  • Harness / Lanyard Required

  • Tie Off Points Required

  • Hoisting of Tools

  • Falling Objects

  • Rescue Plan Required

Access / Egress

  • Slips / Trips

  • Excavation (Snow/Mud/Flooding)

  • Tank / Pit Entry Required

Ergonomic

  • Awkward Body Postion

  • Over Extension

  • Prolonged Period in Same Position

  • Working in Tight Area

  • Lifting Heavy / Awkward Object

  • Body Part in Line of Fire

  • Repetative Motion / Vibration

  • Hands Not in Line of Sight

  • Working Above Head

Personal

  • New On Job

  • No Method of Procedure (MoP) for Task

  • Confusing Instructions

  • No Training on Task / Tools

  • No Experience

  • Cut, Strain, Squeezed, Pinched

Environmental

  • Weather Conditions

  • Provide weather conditions: ie, humidity, sun, rain, clouds, storms, wind snow, ice etc.

  • Extreme Temperatures

  • Temperature

  • Noise in Area

  • Dust / Mist / Fumes

  • Improper Waste Disposal

  • Improper Material Storage

  • Contamination Possible (Water, Soil, Air)

  • Poor Vegitation Management

  • Animals / Insects

  • Other

  • Explain

Other

  • Improper Tools Used

  • Others Working Overhead / Below

  • Energized Work (Permit Required)

  • Hot Work (Permit Required)

  • Confined Space (Permit Required)

  • Ground Disturbance (Permit Required)

  • Other

  • Explain

Eliminate / Control Hazards

Minimum PPE

  • Type A PPE (Min Cal 8/cm2)

  • Hard Hat (Site Specific)

  • Safety Glasses

  • Face Shield

  • Hearing Protection

  • Gloves

  • Safety/Hard Toe Shoes

  • High Visibility Vest / Clothing (Site Specific)

Standard PPE

  • 40 CAL Suit Plus Hood (Full Suit or Combo)

  • Tested Rubber Gloves

  • Leather Protector Gloves

  • Balaclava

  • Other

  • Explain

Specialty PPE

  • Fire Retardant Clothing

  • Respirator / SCBA

  • Fall Protection

  • Personal Monitor

  • Leg Protection (Chaps)

  • Biological / Chemical

  • Other Protection

  • Explain

Tools Required

  • Tools Correct for Task

  • Tools in Good Condition

  • Tools Sufficiently Rated

  • Spill Containment Kit

  • Barricade

  • Specialty Tools

  • List Tools

  • Other

  • Explain

Working Outside

  • Hydration

  • Sunscreen

  • Insect Repellant

  • Proper Hat / Clothing

  • Food / Snacks

  • Other

  • Explain

Testing Equipment

  • 1000Vdc Max Meter

  • 1500Vdc Max Meter

  • Live-Dead-Live Tester

  • Megger

  • Drone

  • Other

  • List

Lockout / Tagout (LOTO)

  • DC Disconnects

  • DC Combiners

  • Inverters

  • AC Combiners

  • AC Disconnects

  • Switch Gear

  • Transformers

  • Point-of-Interconnection

Other Controls

  • List Additional Controls

Task Completion - Close Out

  • Permit(s) Closed Out

  • Explain

  • All Personal Locks Removed

  • Explain

  • Area Cleaned Up Prior To Departure

  • Explain

  • Any Incidents / Near Misses

  • Any Hazards Remaining

  • List Workers Names

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.