Information
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Date &Time:
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Job:
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Sub Contractor:
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Contact #
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Task Location
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Permits / Plans
- Hot / Cold Work
- Confined Space
- Demolition
- Ground Disturbance
- Excavation
- Lockout
- Critical Lift Plan
- Fall Protection Plan
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Permit Identified Hazards
- Hazards Detailed on Safe Work Permit
- Hazards on Critical Lift Permit
- HAzards on Electrical Permit
- Hazards Identified for Confined Space Entry
- Hazards on Confined Space Entry Permit
- Hazards on Hot/Cold Work Permit
- Hazards on Underground/Exgavation Permit
- Hazard on Line OpeningPermit
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Emergency Equipment
- Fire Extinguisher
- Eyewash/Shower
- All Condition Met
- Air Horn
- Extraction Equipment
- Permit Dispalyed
- Alarm #
- Emergency #
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Overhead Or Working At Height Hazard
- Harness Required / Appropriate Tie - Off Identified
- Others Working Overhead / Below
- Falls from Height
- Hoisting or Moving Loads Overhead / Around Task
- Use of Scaffolds
- Tasks Require You to Work Above Your Head
- Objects / Debris Falling from Above
- Overhead Power Lines
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Equipment Hazzard
- Operating Power Equipment
- Operating Motor Vehichle/Heavy Equipment
- Contact with/contact by
- Working with Saws:
- Cutting Torch:
- Hand Tools:
- Grinders:
- Welding Machine:
- Cranes:
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Work Environment Hazarsds
- Weather Conditions
- Waste Material Generated Performing Task
- Limited Access / Egress
- Foreign Bodies in Eyes
- Exposure to Energized Electrical Systems
- Lightening Levels Too High / Too Low
- Position of Fingers / Hands - Pinch Points
- Exposure to Chemicals:
- Sharp Objects / Edges:
- Dust / Particulates:
- Noise:
- Extreme Heat / Cold:
- Odors:
- Reactive Chemicals:
- Stem:
- Fogging of Monogoggles / Eye Protection:
- Flamamble Gases / Atmospheric hazards:
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Personal Limitations / Hazards
- Procedure Not Available for Task
- Confusing Instructions
- No Trainin in Procedure / Task
- No Trainin in Tools to be Used
- First Tine in Performing This Task
- Mental Limitations / Distractions / Loss of Focus
- Not Physically Able to Perform Task
- Complacency
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Welding
- Shields
- Fire Blankets
- Fire Extinguisher
- Cylinder Secured / Secure Connections
- Cylinder Caps On
- Flashback Arrestor
- Combustibles Moved
- Sparks Contained
- Ground within 18"
- Fire Watch / Spark Watch
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Physical Energy
- Load Too Heavy / Awkward to Lift
- Over Reaching
- Prolonged / Extreme Bending
- Repetitve Motions
- |Unstable Position
- Part(s) of Body in "Line of Fire"
- Hands Not in Line of Sight
- Physical Limitation - Need Assistance
- Uncontrolled Release of Energy / Force
- Fall Potential
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Personal Protective Equipment
- Work Gloves
- Chemical Gloves
- Kevlar Gloves
- Rain Gear
- Thermal suits
- Rubber Boots
- Monogoggles / Faceshied
- Safety Glasses
- Respitory Protection
- Hearing Protection
- Safety Harness / Lanyard / Lifeline
- Head Protection
- Steel - Toed Work Boots
- Hi Vis Vest
- Fire Retardant Wear
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Other (Preventative and Protective Measures)
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Is the worker working alone?
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If yes, explain / note the procedure(s) in place:
