Hazard Risk Identification Assessment

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• ACTIVITY DESCRIPTION:

HAZARDS

• 1.1. Height

  Safe

  At Risk

  N/A

• 1.2. Equipment

  Safe

  At Risk

  N/A

• 1.3. Power Lines

  Safe

  At Risk

  N/A

• 1.4. Electricity

  Safe

  At Risk

  N/A

• 1.5. Sharp Objects

  Safe

  At Risk

  N/A

• 1.6. Slippery / Wet Surfaces

  Safe

  At Risk

  N/A

• 1.7. Gasses

  Safe

  At Risk

  N/A

• 1.8. Dust

  Safe

  At Risk

  N/A

• 1.9. Underground Utilities

  Safe

  At Risk

  N/A

• 1.10. Overhead Obstructions

  Safe

  At Risk

  N/A

• 1.11. Hazardous Substances

  Safe

  At Risk

  N/A

• 1.12. Working In Isolation

  Safe

  At Risk

  N/A

• 1.13. Ignition Sources

  Safe

  At Risk

  N/A

• 1.14. Manual Handling

  Safe

  At Risk

  N/A

• 1.15. High Pressure

  Safe

  At Risk

  N/A

• 1.16. Lifting Equipment

  Safe

  At Risk

  N/A

• 1.17. Rotating Machinery

  Safe

  At Risk

  N/A

• 1.18. Entry & Exit

  Safe

  At Risk

  N/A

• 1.19. Ground Openings

  Safe

  At Risk

  N/A

• 1.20. Entanglement

  Safe

  At Risk

  N/A

• 1.21. Animals, Pests

  Safe

  At Risk

  N/A

• 1.22. High Voltage

  Safe

  At Risk

  N/A

• 1.23. Confined Space

  Safe

  At Risk

  N/A

• 1.24. Sun Rays / Adverse Weather Conditions

  Safe

  At Risk

  N/A

• 1.25. Pollution

  Safe

  At Risk

  N/A

• 1.26. Grinding

  Safe

  At Risk

  N/A

• 1.27. Public Areas

  Safe

  At Risk

  N/A

• 1.28. Other Hazards

CONTROL MEASURES

• 2.1. Isolations

  Yes

  No

  N/A

• 2.2. Spotters

  Yes

  No

  N/A

• 2.3. Lighting

  Yes

  No

  N/A

• 2.4. Respiratory Protection

  Yes

  No

  N/A

• 2.5. Application of PPE

  Yes

  No

  N/A

• 2.6. Signage

  Yes

  No

  N/A

• 2.7. Barricades

  Yes

  No

  N/A

• 2.8. Fall Arrest

  Yes

  No

  N/A

• 2.8. Extinguishers

  Yes

  No

  N/A

• 2.9. Screens

  Yes

  No

  N/A

• 2.10. Fire Blankets

  Yes

  No

  N/A

• 2.11. Procedures

  Yes

  No

  N/A

• 2.12. Competent People

  Yes

  No

  N/A

• 2.13. Locating Equipment

  Yes

  No

  N/A

• 2.14. UV Protection

  Yes

  No

  N/A

• 2.15. Gas Detection

  Yes

  No

  N/A

• 2.16. Designated Work Areas

  Yes

  No

  N/A

• 2.17. Supervision of Public

  Yes

  No

  N/A

• 2.18. Other Control Measures

DESCRIPTION OF WORKS & CONTROLS

• 3.1. Job Steps

• 3.2. Risk Description

• 3.3. Controls Description

SIGN OFF

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• Team Member

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• Team Member

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• Team Member

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• Authorized Person: I have reviewed this JSA and agree that it is a fair assessment of the job and I authorize this work to proceed.

• Team Leader

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