Title Page
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Site Name
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Date
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Prepared by
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Job Location
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Service Case Number
Job Site Hazards
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Tasks
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Steps
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Potential Hazards
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Steps to Eliminate/Control
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Lockout - Tagout Required?
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Safety Barrier Required?
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Is the worker working alone?
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What additional control measures taken for solo work?
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Permit(s) Required?
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What control measures taken?
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Are instruments calibrated?
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Write Equipment ID # and Calibration Date
Job Hazards
Electrical Hazards
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Testing of Energized Equipment
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Energized Device - DC
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DC Voltage
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Energized Device - AC
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AC Voltage
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Arc Flash Risks
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Proper Tools NOT Available
Work Area Hazards
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Critical Lifting
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No Delimitation Barricades / Signs
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Other Workers In Area (Conflicting Work)
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Simultaneous Activity
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Working Alone (Attach Rescue Plan)
Site Specific Conditions
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Holes, Ditches, Trenches
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Low Obstructions (Overhead)
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Falling Item / Material
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Overhead Power
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Potential Gas
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Fire / Explosion Risk
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Lighting Levels Too Low
Working From Heights
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Height of Work
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Aerial Lift / Man Basket Required
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Scaffold Required
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Ladders Required
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Harness / Lanyard Required
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Tie Off Points Required
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Hoisting of Tools
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Falling Objects
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Rescue Plan Required
Access / Egress
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Slips / Trips
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Excavation (Snow/Mud/Flooding)
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Tank / Pit Entry Required
Ergonomic
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Awkward Body Postion
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Over Extension
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Prolonged Period in Same Position
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Working in Tight Area
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Lifting Heavy / Awkward Object
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Body Part in Line of Fire
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Repetative Motion / Vibration
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Hands Not in Line of Sight
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Working Above Head
Personal
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New On Job
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No Method of Procedure (MoP) for Task
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Confusing Instructions
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No Training on Task / Tools
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No Experience
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Cut, Strain, Squeezed, Pinched
Environmental
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Weather Conditions
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Provide weather conditions: ie, humidity, sun, rain, clouds, storms, wind snow, ice etc.
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Extreme Temperatures
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Temperature
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Noise in Area
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Dust / Mist / Fumes
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Improper Waste Disposal
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Improper Material Storage
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Contamination Possible (Water, Soil, Air)
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Poor Vegitation Management
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Animals / Insects
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Other
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Explain
Other
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Improper Tools Used
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Others Working Overhead / Below
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Energized Work (Permit Required)
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Hot Work (Permit Required)
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Confined Space (Permit Required)
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Ground Disturbance (Permit Required)
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Other
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Explain
Eliminate / Control Hazards
Minimum PPE
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Type A PPE (Min Cal 8/cm2)
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Hard Hat (Site Specific)
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Safety Glasses
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Face Shield
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Hearing Protection
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Gloves
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Safety/Hard Toe Shoes
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High Visibility Vest / Clothing (Site Specific)
Standard PPE
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40 CAL Suit Plus Hood (Full Suit or Combo)
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Tested Rubber Gloves
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Leather Protector Gloves
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Balaclava
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Other
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Explain
Specialty PPE
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Fire Retardant Clothing
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Respirator / SCBA
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Fall Protection
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Personal Monitor
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Leg Protection (Chaps)
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Biological / Chemical
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Other Protection
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Explain
Tools Required
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Tools Correct for Task
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Tools in Good Condition
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Tools Sufficiently Rated
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Spill Containment Kit
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Barricade
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Specialty Tools
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List Tools
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Other
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Explain
Working Outside
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Hydration
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Sunscreen
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Insect Repellant
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Proper Hat / Clothing
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Food / Snacks
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Other
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Explain
Testing Equipment
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1000Vdc Max Meter
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1500Vdc Max Meter
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Live-Dead-Live Tester
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Megger
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Drone
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Other
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List
Lockout / Tagout (LOTO)
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DC Disconnects
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DC Combiners
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Inverters
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AC Combiners
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AC Disconnects
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Switch Gear
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Transformers
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Point-of-Interconnection
Other Controls
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List Additional Controls
Task Completion - Close Out
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Permit(s) Closed Out
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Explain
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All Personal Locks Removed
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Explain
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Area Cleaned Up Prior To Departure
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Explain
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Any Incidents / Near Misses
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Any Hazards Remaining
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List Workers Names