FIELD LEVEL HAZARD ASSESSMENT FORM (FLHA)

• Conducted on

  Date

• Prepared by

• Location
  Address

• FLHA#

  Yes

  No

  N/A

• Task to be Done:

• Date:

  Date

Emergency Assembly Area:

• Task Location:

• Start of Shift or

  Yes

  No

  N/A

• New Job/Location

• COMPLETE PRIOR TO WORKING, AND AS NEW HAZARDS or LOCATIONS ARE INTRODUCED

  Yes

  No

  N/A

• In case of incident the following people will be contacted immediately - Supervisor: Manager: H&S:

• Consider the Following In Your Hazard Assessment

• Hazardous parts of the job?

  Yes

  No

  N/A

• What do you need to complete the task?

  Yes

  No

  N/A

• What obstacles might you encounter when completing the task?

• Have there been any incidents doing this before?

  Yes

  No

  N/A

• Who else might your task involve or affect?

• What might you need to ensure this task is completed incident free?

• If conditions change then STOP & revise FLHA

  Yes

  No

  N/A

• Fit for Duty

  Yes

  No

  N/A

• 1) Have you sustained an injury offsite

  Yes

  No

  N/A

• 2) Are you currently affected by any drugs, alcohol or medication

  Yes

  No

  N/A

• 3) Are you feeling affects of sleep deprivation

  Yes

  No

  N/A

• 4) Are you affected by illness

  Yes

  No

  N/A

• Yes No INITIALS

• **If YES, Please report to Supervisor, Prior to Starting Shift**

• TASK BEING PERFORMED

  Yes

  No

  N/A

3 HAZARDS FOR EACH TASK

PLANS TO ELIMINATE OR CONTROL EACH HAZARD

• PPE

  Yes

  No

  N/A

• Needed

  Yes

  No

  N/A

• Traction Aides

  Yes

  No

  N/A

• Safety Glasses

  Yes

  No

  N/A

• Cut Resistant Gloves

  Yes

  No

  N/A

• Hair Net

  Yes

  No

  N/A

• Peer-to-Peer

  Yes

  No

  N/A

PPE CHECK

• Name:

• Time:

  Date

• Wet Conditions Footwear

  Yes

  No

  N/A

• Chemical Goggles

  Yes

  No

  N/A

• Chemical Gloves

  Yes

  No

  N/A

• FR Clothing

  Yes

  No

  N/A

• Safety Toed Footwear

  Yes

  No

  N/A

• Hard Hat

  Yes

  No

  N/A

Chemical Apron

• Other

  Yes

  No

  N/A

• List Chemicals or Hazardous Substances

• Reviewed MSDS

  Yes

  No

  N/A

• Location of MSDS

• Chemical

  Yes

  No

  N/A

• List chemicals or

Hazardous Substances:

Environmental

• Weather:

  Yes

  No

  N/A

• Temp:

• Terrain:

  Yes

  No

  N/A

• Wildlife:

  Yes

  No

  N/A

• Associate sign prior to commencing work

  Yes

  No

  N/A

• PRINT NAME

• SIGNATURE

  Sign

Twelve Life Saving Rules

• Work with a valid work permit

  Yes

  No

  N/A

• Conduct Gas Conduct gas Tests when Required

  Yes

  No

  N/A

• Verify Isolation Before Work begins

  Yes

  No

  N/A

• Protect yourself against a fall when working at height

  Yes

  No

  N/A

• Do not smoke outside designated smoking areas

  Yes

  No

  N/A

• No alcohol or drugs while working or driving

  Yes

  No

  N/A

• While driving, do not use your phone and do not exceed speed limits

  Yes

  No

  N/A

• Wear your seat belt

  Yes

  No

  N/A

• Do not Walk under a suspended Load

  Yes

  No

  N/A

• Obtain Authorization before overriding or disabling safety critical equipment

  Yes

  No

  N/A

• Obtain Authorization before entering a Confined Space

  Yes

  No

  N/A

Follow Prescribed Journey Management Plan

• IF IN DOUBT,

  Yes

  No

  N/A

• DON’T DO IT!

  Yes

  No

  N/A

• McMurray Coin is committed to providing a productive, safe and healthy work environment for our employees, customers and visitors

  Yes

  No

  N/A

• Examine each step to find and identify hazards or dangers that could lead to injury or damage. Consider:

  Yes

  No

  N/A

PHYSICAL HAZARDS

Pressure Heights Electricity

Stress Physical Dynamic

Situations

Natural Environment

CHEMICAL/BIOLOGICAL

Chemical Hydrocarbons Biological

• Toxic

  Yes

  No

  N/A

PEOPLE

• Yes

  No

  N/A

Security Psychological Ergonomic

JOB COMPLETION

• Are you aware of any unsafe conditions that could harm persons or the site

  Yes

  No

  N/A

• Were there any injuries or incidents?

  Yes

  No

• Was the injury or incident reported to your supervisor?

  Yes

  No

  N/A

• **If YES to any of the above, Please fill out the proper documentation and report to Supervisor Immediately**

• Have you added or removed any lockout/tagout mechanisms? (including Signs, Tape, Ribbons)

  Yes

  No

  N/A

Supervisor / Manager Review

• Print Name

• Signature

  Sign

SUPERVISOR/MANAGER FIELD CHECK

HSE FIELD CHECK

JHSC FIELD CHECK

• TIME:

• AUDITED BY:

• SIGNATURE:

  Sign