HAVS Risk Assessment Template

• Site

• Location
  Address

• Shift

• Full Name of Construction Worker

• Date of Assessment

  Date

HAVS Risk Assessment

• Task Description

• Vibrating tool or equipment used to complete task

TOOL

• Select vibrating tool or equipment used

  Select Concrete breaker Hammer drill Grinder Disc Cutter Sander Chipping hammer Needle gun Other

  • Concrete breaker
  • Hammer drill
  • Grinder
  • Disc Cutter
  • Sander
  • Chipping hammer
  • Needle gun
  • Other

• Specify vibrating tool or equipment

• Start Time of Vibrating Tool or Equipment Use

  Date

• End Time of Vibrating Tool or Equipment Use

  Date

• Trigger Time

HAVS Check

• Do my hands feel numb during/after using vibrating tool/s or equipment?

  Yes

  No

• Inform your team manager about a potential HAVS symptom you are experiencing.

• Are my hands tingling after using vibrating tool/s or equipment?

  Yes

  No

• Inform your team manager about a potential HAVS symptom you are experiencing.

• Are my fingers turning white and becoming red and painful on recovery?

  Yes

  No

• Inform your team manager about a potential HAVS symptom you are experiencing.

Completion

• Additional Observations

• Full Name and Signature of Construction Worker

  Sign