Hazard Assessment (York)

• Conducted on:

  Date

• Building / Site Name:

• Building / Site Address
  Address

• Completed by:

  Select

• Water-Fed Pole System Window Cleaning

• Squeegee Window Cleaning

• Additional Tasks

Tasks

• Task:

Access

• Ladder

• Other Methods

Method:

• Method:

Weather

• Wind

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Rain

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Lightening

  No

  Yes

  N/A

• Severity: (2) Serious Danger - severe injury or illness, property damage

• Probability: (C) Remote - could occur at some point

• Excessive Sun Exposure

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (B) Reasonably Probable - likely to occur eventually

• Cold Weather

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (B) Reasonably Probable - likely to occur eventually

Overuse Injuries

• Heavy Lifting

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Awkward Body Position(s)

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Repetitive Motions

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (B) Reasonably Probable - likely to occur eventually

Site Specific

• Slip or Trip

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Power Lines and/or Electrical Boxes

  No

  Yes

  N/A

• Severity: (1) Imminent Danger - causing death, loss of facilities

• Probability: (C) Remote - could occur at some point

• Landscaping Obstacles (Slopes, Embankments, Uneven Ground, Trees, etc.)

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Architecture Obstacles (Fences, Buildings, Desks, Stairs, etc.)

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Cuts or Scratches

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Parked Cars

  No

  Yes

  N/A

• Severity: (3) Minor Danger - non-serious injury, illness, or damage

• Probability: (C) Remote - could occur at some point

• Vehicle or Pedestrian Traffic

  No

  Yes

  N/A

• Severity: (2) Serious Danger - severe injury or illness, property damage

• Probability: (C) Remote - could occur at some point

• Fall From More Than 3m

  No

  Yes

  N/A

• Severity: (2) Serious Danger - severe injury or illness, property damage

• Probability: (C) Remote - could occur at some point

Additional Hazards

• Additional Hazards:

Hazard:

• Hazard:

• Description:

• Severity:

  (1) Imminent Danger - causing death, loss of facilities

  (2) Serious Danger - severe injury or illness, property damage

  (3) Minor Danger - non-serious injury, illness, or damage

  (4) Not Applicable

• Probability:

  (A) Probable - likely to occur immediatly or soon

  (B) Reasonably Probable - likely to occur eventually

  (C) Remote - could occur at some point

  (D) Extremely remote - unlikely to occur

• Add Photo:

  Media

Mandatory Controls

• Group Communication Established

• Workers Trained in Task or Supervised by a Competent Worker

• Inspection of Equipment

• Correct Certificates(s) Held (i.e. Fall Protection, Lift, Tower Rescue, etc.)

• Signage/Cones Used

• Weather Monitoring

• Active Stretching

• Micro-Breaks

PPE Controls

• Skin Protection (i.e. Sun Block, Long Sleeve Shirt, Etc.)

• Shoes With Good Soles

• Safety Vest

• Additional PPE

PPE

• PPE:

Site Specific Controls

• Proper Lifting Technique Used

• Safe Working Area Established When Near Power Lines

• Proper Ladder Technique Used

• Traffic Spotter Used

• Additional Controls:

Control

• Control:

• I hereby certify that all information is accurate and that an actual inspection was conducted as per company policy.

• Crew Manager's Printed Name & Signature

  Sign

• Worker's Printed Name & Signature

Worker:

• Add signature

  Sign