Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
Severity+Probability=Priority (Eg. Worker at heights without Fall Protection - 1A) (1 life threatening, 2 serious, 3 Minor) (A likely to happen to E NOT likely to happen)
INSTRUCTIONS: Identify potential hazard, prioritize and write the control for the hazard
1. GENERAL INFORMATION
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1.1 Task Location
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1.2 Task to be performed:
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1.3 PPE Inspected?
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1.4 Muster Point designated?
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1.5 Emergency Response Plan available?
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1.6 Emergency Equipment Available?
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1.7 Required number of First Aiders available?
2.0 ENVIRONMENTAL HAZARDS
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2.1 Work Area Clean<br>
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2.2 Material Storage Identified
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2.3 Dust/Mist/Fumes
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2.4 Noise in Area
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2.5 Extreme Temperatures/ weather conditions
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2.6 Spill Potential
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2.7 Waste Properly Managed
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2.8 Other Workers in Area
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2.9 Ground Disturbance
3.0 ERGONOMIC HAZARDS
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3.1 Prolonged Twisting/Repetitive/Bending Motion
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3.2 Working in a Tight Area
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3.3 Lift too heavy/Awkward to Lift
4.0 ACCESS/EGRESS HAZARDS
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4.1 Aerial Lift/Man Basket (Inspected & Tagged)
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4.2 Scaffold (Inspected & Tagged)
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4.3 Ladders Tied Off
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4.4 Slips/Trips
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4.5 Hoisting ( tools, equipment)
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4.6 Confined / Restricted Space Entry (Permit required?)
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4.7 Excavation
5.0 OVERHEAD HAZARDS
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5.1Power Lines
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5.2 Hoisting or Moving Loads Overhead
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5.3 Falling Objects
6.0 FALL PROTECTION AND GENERAL SAFEGUARDS
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6.1 Hole Coverings Identified
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6.2 Harness/Lanyard Inspected
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6.3 100% Tie-off with Harness and Anchor Points Identified (Fall Protection Plan available)<br>
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6.4 Roof openings (Control Zones)
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6.5 Guardrails
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6.6 Tools, equipment and machinery have proper safeguards?
7.0 RIGGING & HOISTING HAZARDS
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7.1 Rigging Plan Available for Review?
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7.2 Proper Tools Used
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7.3 Tools/Slings Inspected
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7.4 Equipment Inspected
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7.5 Critical Lift Permit Required?
8.0 ELECTRICAL HAZARDS
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8.1 Certified, competent, electrical worker
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8.2 Working On / Near Energized equipment
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8.3 Electrical Cords/tools condition
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8.4 Fire Extinguisher
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8.5 Hot Work or Electrical Permit required
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8.6 Verification of lockout/tagout. (De-Energized)
9.0 PERSONAL LIMITATIONS HAZARDS
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9.1 Procedure Not Available for Task
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9.2 Confusing Instructions or No Instructions Available.
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9.3 No Training for Task or Tools to Be Used
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9.4 First Time Performing the Task
10.0 POWERED MOBILE EQUIPMENT
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10.1 Powered mobile equipment including vehicles working at site
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10.2 Powered Mobile equipment method to de-energize
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10.3 High visibility clothing available
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10.4 Traffic Control
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10.5 Driving
11.0 CHEMICAL OR BIOLOGICAL HAZARDS
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11.1 Air Quality
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11.2 Ventilation
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11.3 Temporary Heat sources
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11.4 Asbestos
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11.5 MSDS Reviewed
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11.6 Respiratory Equipment
11.0 ADDITIONAL CONTROLS TO ELIMINATE HAZARDS
12.0 GENERAL TOOLBOX MEETING OR TOPIC OF DISCUSSION
13.0 Has any equipment been locked out/tagged out or removed from service? Explain.
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13.1 Locked, tagged or removed from service? explain if yes.
All workers must sign onto FLHA prior to work commencing. If any new workers show up onto site they must review this FLHA and sign on as we'll.
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Lead Supervisor / Company
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Worker Name / Company
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Worker Name / Company
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Worker Name / Company
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Worker Name / Company
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Worker Name / Company
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Reviewed by: Company Representative
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Reviewed by: Safety Represntative
