Title Page
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Conducted on
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Prepared by
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Location
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Site Supervisor:
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Project Number :
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Other Attendees:
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* If hazard exists (at-risk) fill in the notes with the description of the hazard and corrective action plan.
* Priority (status) based on seriousness of hazard
# 1 Immediate Danger - Possible Death - Project Shutdown # 2 Serious Hazard - Major Injury - Significant Project Disruption # 3 Moderate Hazard - Minor Injury - Some Project Disruption # 4 Minor Hazard – First Aid or Less - Low Impact on Project -
Waste Disposal/ Housekeeping
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Material Storage/ Handling
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Confined Space Entry
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Traffic Control/ Restrictions
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Overhead Hazards
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Underground Hazards
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Flammables (Fire/Explosion)
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Hazardous Chemicals
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Dangerous Pressure & Vacuum
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Lifting and Carrying
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Cables/ Ropes/ Chains/ Slings
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Vehicle/Machine Condition
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Gas ( Toxic or Nontoxic)
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Electrical Wiring & Guards
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Hot Work
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Ergonomics
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Wildlife and Insects
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Pinch Points
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Personnel Training/Knowledge/ Skills
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Working From Heights or Excavations
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Weather Conditions
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Lighting/ Noise/ Vibration
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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TDG
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Emergency Preparedness
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Mobile Equipment
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Ventilation
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Trips, Slips and Falls
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Permits
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Protection for the Public
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Crane Usage
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Pipe Handling
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Priority of the hazard
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Description of hazard:
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Corrective Action Implemented:
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Follow-up Signature
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Due Date
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Manager's Signature (required):
PPE Required
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Hard Hat
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Safety Glasses
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Hearing Protection
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Fire Resistant Coveralls
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Gloves
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Respiratory Protection
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Steel Toed Boots
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Fall Protection
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Splash Resistant Clothing
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Face Shield
Monitoring
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H2S Alive
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% LEL
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CO
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O3
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O2
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Ozone
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Chlorine
Safety Equipment
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Fire Extinguisher
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Eye Wash
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First Aid Kit
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Horn or Alarm
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Signs
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Barricades
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SDS (WHMIS)
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Cell Phone
Emergency Contacts
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Project Manager:
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Contact #:
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Safety Officer:
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Contact #:
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Muster Area:
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Emergency # if different from 911:
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Onsite First Aid Attendant(s):