Information
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Audit Title
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Client / Site
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Conducted on
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Date of Assessment
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Time of Assessment
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Location
ASSESSMENT TEAM
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Name And Position
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Name And Position
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Name And Position
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Name And Position
PRIORITY CHART(use to fill out the following Hazards)
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SEVERITY
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1. Very Hazardous(previous incident or high potential of incident)
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2. Hazardous
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3. Low Risk
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4. Okay
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5. Not Applicable(N/A)
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PROBABILITY
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A. Probable
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B. Reasonable Probable
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C. Remote
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D. Extremely Remote
Identified Hazards, Activities & Conditions
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Item #1 Housekeeping
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Priority
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Description of
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Item #2 Waste Disposal
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Priority
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Description of
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Item #3 Personal Protective Equipment
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Priority
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Description of
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Item #4 First Aid Kits
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Priority
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Description of
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Item #5 Fire Extinguishers
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Priority
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Description of
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Item #6 Lighting
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Priority
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Description of
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Item #7 Ventilation
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Priority
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Description of
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Item #8 Noise Hazard
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Priority
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Description of
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Item #9 Electrical Hazards
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Priority
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Description of
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Item #10 Hazardous Chemicals/Materials
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Priority
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Description of
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Item #11 Flammables(fire/explosion)
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Priority
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Description of
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Item #12 Vehicle Condition
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Priority
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Description of
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Item #13 Equipment Condition
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Priority
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Description of
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Item #14 Power Tool Condition
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Priority
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Description of
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Item #15 Hoisting/Lifting
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Priority
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Description of
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Item #16 Cables/Ropes/Chains/Slings
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Priority
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Description of
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Item #17 Hoses Air/Paint
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Priority
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Description of
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Item #18 Ladders
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Priority
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Description of
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Item #19 Scaffolds/Staging
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Priority
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Description of
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Item #20 Material Storage/Handling
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Priority
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Description of
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Item #21 Overhead Hazards
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Priority
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Description of
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Item #22 Work at Heights
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Priority
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Description of
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Item #23 Extreme Temperature Hot/Cold
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Priority
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Description of
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Item #24 Confined Space Entry
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Priority
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Description of
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Item #25 Restricted Access/Egress
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Priority
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Description of
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Item #26 Shoring/Sloping/Excavation
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Priority
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Description of
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Item #27 Barricades/Restrictions
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Priority
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Description of
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Item #28 Water/Erosion
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Priority
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Description of
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Item #29 Weather Conditions
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Priority
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Description of
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Item #30 Protection to Public
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Priority
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Description of
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Item #31 Other
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Other Hazard
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Priority
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Description of
HAZARD ASSESSMENT CORRECTIVE ACTION - STEP 2
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Give Corrective Actions for the Hazards Identified
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Item #
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Priority
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Recommended Action
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Date of Action Taken
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Time of Action Taken
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By Whom
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Comments
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Reviewed by Management
