Title Page
-
Site
-
Location
-
Full Name of Safety Officer
-
Date of Assessment
HAVS Assessment
-
Briefly describe the work activities that require workers to use vibrating tools and equipment.
-
Workers exposed to HAVS risks
WORKER
-
Full Name
-
Source of Vibration
TOOL
-
Select vibrating tool or equipment
- Concrete breaker
- Hammer drill
- Grinder
- Disc Cutter
- Sander
- Chipping hammer
- Needle gun
- Other
-
Specify vibrating tool or equipment
-
Vibration Magnitude
-
Trigger Time
-
Exposure Points
-
Exposure Level
-
Select control of exposure
- Eliminated vibration exposure
- Applied time limit
- Reduced vibration exposure
- Applied job rotation
- Trained worker
- Replaced tool or equipment
- Repaired tool or equipment
- Other
-
Specify control of exposure
Completion
-
Additional Recommendations
-
Full Name and Signature of Safety Officer