Non-Standard Work Form Rev. 9

• Prepared By?

• Service Job Number:

• Machine Serial Number:

• Conducted on

  Date
• Job Site Location
  Address

• Briefly describe the work being done today.

• Is the machine inside or outside?

  Inside

  Outside

• When Temperatures are below 32°F or above 80°F, be sure to dress appropriately for the conditions and take breaks as needed.

Safety & Job Pause

• The HSE’s definition of a risk assessment is: “….a careful examination of what, in your work, could cause harm to people, so that you can weigh up whether you have taken enough precautions or should do more to prevent harm….”

• I will perform this risk assessment of the job to the best of my ability. I will follow the procedures that are outlined within this assessment and pause the job if something should occur that isn't planned. Report all job pauses to management via phone, text, or email. If you are unable to correct a job pause with the resources on site, contact management immediately.

• Safety Saves Lives

  

Team Members, Non-Team members & 3 way Communication

• Who has site authority?

  Select

• List other TM on site today.

  Select

• List Additional people on site.

• Anytime you are working with someone or someone comes in the working area, make sure they aware of "Who Has Site Authority" and the "3 Way Communication" that needs to be followed to keep everyone in the area safe. Some examples of 3 Way Communications are below, but not limited to:

• Starting machine

• Locking out or removing a lock

• Moving the machine

• Safe Zones for: Parking/standing/where to stand while machine is running/ etc...

• Any requirements that the company you are visiting. hard hat/high viz vest/parking/standing area etc...

PPE ,Fire Control, Rigging & Rescue Plan

• Are you equipped with the proper PPE for the job and is it in good working condition?

  Yes

  No

• JOB PAUSE: Paused the job until proper PPE can be obtained.

• What did you do to fix the problem?

  Select Remove Reduce Redirect Absorb Distance Shield Change Rate

  • Remove
  • Reduce
  • Redirect
  • Absorb
  • Distance
  • Shield
  • Change Rate

• What "Other" solution did you use to fix this problem?

• Does the job require rigging of any parts? Life Saving Behaviors. -I follow my lifting plan: No Plan, No Lift.

  Yes

  No

• Inspect all rigging equipment, Crane and straps verify they are suitable for the job?

• Does the job require the use of torches, welder, grinder or anything else that can cause a fire?

  Yes

  No

• Do you have all necessary equipment to prevent fire, or in the case a fire does start to extinguish it?

  Yes

  No

• JOB PAUSE: If you are unable to correct a job pause with the resources on site, contact management immediately. Report all job pauses to management via phone, text, or email.

• Definition of confined space: A confined space has limited or restricted means for entry or exit and is not designed for continuous occupancy.

• Does the job require you to enter a confined space?

  Yes

  No

• What is your rescue plan for entering a confined space? There must be a minimum of 2 people present in order to enter a confined space.

• Is a fall restraint required for the job?

  Yes

  No

• Do you have the proper equipment to perform the job safely.

  Yes

  No

• JOB PAUSE: Paused the job until proper equipment can be obtained.

Energy Wheel

• Starting from the inside out; evaluate the environment, tasks, and systems involved with the job. Next, identify the hazardous energies that need to be controlled within the environment, task and systems. Keep in mind that some systems or task can fall in multiple sections of the energy wheel. The outside of the wheel describes the controls to be used. If the hazards cannot be controlled, Pause The Job!

  

• Are you and the machine in a safe environment with acceptable ground and site conditions?

  Yes

  No

• JOB PAUSE: If you are unable to correct a job pause with the resources on site, contact management immediately. Report all job pauses to management via phone, text, or email.

• What ENERGY sources are being worked on?

  Select Electrical Hydraulic Mechanical Pneumatic

  • Electrical
  • Hydraulic
  • Mechanical
  • Pneumatic

• Identify all HAZARDOUS energy.

  Select Pressure Electrical Radiation Chemical & Biological Physical & Mental Gravity Motion Temperature

  • Pressure
  • Electrical
  • Radiation
  • Chemical & Biological
  • Physical & Mental
  • Gravity
  • Motion
  • Temperature

• How will the HAZARDOUS energy be CONTROLLED?

  Select Remove Reduce Redirect Absorb Distance Shield Change Rate

  • Remove
  • Reduce
  • Redirect
  • Absorb
  • Distance
  • Shield
  • Change Rate

Removal of Controls

• Once the job has been completed you will need to remove the controls and test the system to ensure proper functionality.

• 

Returning or Completion of Job.

• If I must return the next day, I will inform someone that I am leaving for the day and give a brief update of my progress.

• Upon completion of the job, I will leave the job site as clean or better as when I arrived. I will inform someone that the job is complete and the machine is ready to be used.

• I will have my paper worked sign by the appropriate person at the site.