Title Page

  • Audit Title

  • Customer

  • Conducted on

  • Person Conducting Assessment

  • Location of Task
  • Description of Activity

Field Level Hazard Assessment

  • Answer the following questions by selecting YES or NO

    You can add Media, Notes and Actions as necessary by clicking on the paper clip icon on the upper right corner of the question.
    - Upload images through the Add Media option.
    - Indicate notes through the Add Note option.
    - Assign to another user with a priority level and due date, and they will be notified in real-time via email, text (SMS) or push notification through the Add Action option.

Evaluating Your Work Area and Tasks

  • Have you walked the area?

  • Do you have PPE available?

  • Are you working around live systems?

  • Does this task require special training?

  • Are underground utilities located?

  • Tools and equipment inspected?

  • Are work permits required?

  • Tools and material available?

  • Are evacuation routes established?

  • Are there previously unidentified safety issues?

  • Are fire extinguishers and First Aid available?

  • Is a fall protection plan required?

  • Have all workers attended the Site Specific Safety Orientation?

  • Have we co-ordinated activities with other subcontractors?

  • New/Young Worker on Crew?

  • New Tools or Equipment?

  • Adequate Time and Crew Provided to Complete Tasks?

  • Adequate Tools and Equipment?

Potential Hazard Checklist

Potential Hazard Checklist

  • Identify the Potential Hazard Checklist by selecting items on the dropdown list:

  • What other hazard is present?

PPE Required

  • Check the PPE Requirement if available.

  • Hard Hat

  • Hi-Visibility Vest

  • Safety Boots

  • Eye Protection

  • Gloves

  • Respirators

  • Face Shield

  • Ear Protection

RISK ASSESSMENT

RISK ASSESSMENT

  • RISK ASSESSMENT MATRIX

    Risk Scoring matrix.jpg
  • Risk Assessment:
    1-5 is considered Low Risk: work may commence
    6-10 is considered Moderate Risk: Action needs to be taken to eliminate or minimize risk prior to work commencing
    11-15 is considered High Risk: Immediate action must be taken to eliminate or minimize risk down to a Low to Moderate Risk with controls in place prior to work commencing. If this is not possible then job task cannot commence
    16-25 is considered Extreme Risk: Job shutdown, urgent action must be taken to eliminate or minimize risk down to a Low or Moderate Risk with controls in place prior to work commencing. If this is not possible then the job task cannot commence

    Click the ADD button to add a TASK
    Step 1 - Identify the Task
    Step 2 - Identify the Hazards
    Step 3 - Conduct Risk Assessment by using the Matrix above
    Step 4 - Actions to Eliminate / Control Hazard

  • Add TASK and identify the HAZARDS

  • Task
  • Step 1 Identify Task

  • Step 2 Identify Hazards

  • Step 3 Conduct Risk Assessment

  • Low Risk: work may commence

    low.PNG
  • Moderate Risk: Action needs to be taken to eliminate or minimize risk prior to work commencing

    moderate.PNG
  • High Risk: Immediate action must be taken to eliminate or minimize risk down to a Low to Moderate Risk with controls in place prior to work commencing. If this is not possible then job task cannot commence

    high.PNG
  • Extreme Risk: Job shutdown, urgent action must be taken to eliminate or minimize risk down to a Low or Moderate Risk with controls in place prior to work commencing. If this is not possible then the job task cannot commence

    extreme.PNG

    Click ADD to SIGN
  • Worker Full Name and Signature

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.