HSE Field Level Risk Assessment

Field Level Risk Assessment

• Project No.

• Customer Name:

• Location
  Address

• Conducted on

  Date

• Conducted by:

• Supervisor Name:

• Other Employees or Sub-Contractors present:

Instructions: Step 1. Complete FLRA prior to starting task and/or prior to changes in work environment, work activities, equipment/tools and people. Review the FLRA with co-workers/sub-contractors involved in the work activity or affected by it.Step 2: Identify each hazard present as either: a) present and safe if LOW RISK defined as probability is rare/unlikely/likely AND severity is negligable / minor (first aid), b) present and at risk if MEDIUM RISK defined as probability is rare/ unlikely/ likely / highly likely / almost certain AND severity is serious (medical aid required / major / catastrophic), or c) Present and Unsafe: if HIGH RISK defined as probability is almost certain and minor, serious, major or catastrophic) . Step 3: For each hazard identified, two option 1) use the action button at the bottom of the screen to describe the control you will put in place using the hierarchy of controls, or 2) select the controls further down in the tool Step 4: AFTER CONTROLs ARE PUT IN PLACE: if any residual risks identified remain MEDIUM or HIGH: they MUST be reviewed with Supervisor PRIOR to starting work activity. This MUST be documented by text / email / verbal approval of supervisor. Step 5: Email the completed FLRA to your supervisor after completion of the work.

• Describe the work activity to be performed:

HAZARD IDENTIFICATION

High and Medium Risk Activities

• Activities to be performed include sources of hazardous energy (lockout-tagout), working at height (incl. roof), elevated work platforms or mobile equipment, electrical work, hot work, line breaking, cranes, confined spaces, powered manual tools, sharp objects, chemical or biological exposures, hazardous materials, hazardous waste, demolition, or excavation?

  Yes

  No

  N/A

• Work performed at/above 1.2m (4') or at/within 1.8m (6') of roof edge/ledge?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Access needed to reach areas above guard rail, barrier? e.g. fire protection systems, lights, sensors in ceiling on equipment at height etc.?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Edge protection, barriers, guardrails?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Engineered and certified tie-off points (=5,000Kg)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Wet, contaminated, slippery surfaces or handles/rails?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Adequate space to use scissor lift or similar device to access work at height?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Hazards from sharp edges, materials, equipment, facility infrastructures?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Situation requiring harness (inspected, retractable life line, anchor points, rescue plan)

  Safe

  At Risk

  Unsafe

  Not Applicable

• Harness and equipment (pre-use inspected / external, labeled, complete, compatible parts (hooks, etc.), < 5years) and in good condition?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Fall prevention training and certification current for operators?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Ladders / steps used to access height? --inspected, tied off, materials appropriate, 4-1 angle, etc.

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Hazardous Energy

• Potential exposure to hazardous energy sources (electrical, pneumatic, hydraulic, kinetic, etc.) when working on equipment/machines/ or nearby?

  Yes

  No

  N/A

• Lockout-tagout kit adequate (personal, group) and readily available?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any troubleshooting on energized equipment? -complete non-routine work risk assessment-

  Yes

  No

  N/A

• Verification of zero energy completed after lockout-tagour for all hazardous energy sources related to work activity?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Lockout-tagout start and end communicated to persons affected by LTV?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Lockout-tagout competent person / training current?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Electrical working on or near

• Power Lines nearby and / or above? --contact utility company-

  Safe

  At Risk

  Unsafe

  Not Applicable

• Working near exposed electrical conductors? -electrical work rubber gloves, liners with appropriate rating and tested within last 6 months, stored flat, etc.

  Safe

  At Risk

  Unsafe

  Not Applicable

• Electrical work performed >50Volts?

  Yes

  No

  N/A

• GFCI tested?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Cords and equipment in good condition?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Extension cords used for temporary purposes only? -rated for intended use-

  Safe

  At Risk

  Unsafe

  Not Applicable

• Unsafe electrical leads? (damaged, out of test date or untested)

  Safe

  At Risk

  Unsafe

  Not Applicable

• Overloaded outlets?<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Electrical equipment near water or flammables or sources of ignition? -rating<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Bonding and grounding?<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Electrically classified area? -spark / explosion proof tools-

  Safe

  At Risk

  Unsafe

  Not Applicable

• Live electrical work performed or electrical work > 240 Volts?

  Yes

  No

  N/A

• Competent person performs risk assessment, determines and implements controls?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Electrical controls (arc flash, current) using hierarchy of controls readily available and used?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Permit in place and effective controls implemented? -reviewed with supervisor-

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

Elevated Work Platforms and Mobile Equipment

• Elevated Work Platforms or Mobile Equipment (Manlift, scissorlift, fork-truck etc.) expected to be used or are you working in close vicinity of these?

  Yes

  No

  N/A

• Daily pre-use inspection completed and deficiencies corrected?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Operator certified / trained and current?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Fall protection systems in place and effective? anchor points

  Safe

  At Risk

  Unsafe

  Not Applicable

• Equipment extensions (certified / weight load limit indicated) or slings (nylon, steel, rope) inspected, appropriately rigged and adequate for the weight load / task / environment and in good condition?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Access of equipment to work location evaluated? -struck by / struck against

  Safe

  At Risk

  Unsafe

  Not Applicable

• Equipment movement in work area evaluated? -struck by / struck against

  Safe

  At Risk

  Unsafe

  Not Applicable

• Load movement out of sight or with limited visibility? spotter / signaling person required

  Safe

  At Risk

  Unsafe

  Not Applicable

• Are barricades and warning signs in place when working at height, on roof / near edges, hazardous processes, moving equipment, cranes, lifting equipment, etc.?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Roof-top access required? -roof risk assessment, permit

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any battery / electrical charging stations or compressed gas exchange required? -eyewash stations / safety showers if corrosives in place, proper secured storage and handling of compressed gas cylinders --do NOT roll--

  Safe

  At Risk

  Unsafe

  Not Applicable

• People and moving equipment separated by barricades or similar? If not, use spotter

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Cranes

• Cranes used or in / around work area?

  Yes

  No

  N/A

• Daily pre-use inspection completed and deficiencies corrected?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Operator certified and current?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Maintenance, testing and inspection records up-to-date and deficiencies corrected?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any extensions (certified and weight load limit indicated) or slings (nylon, steel, rope) inspected, appropriately rigged and adequate for the weight load / task / environment and in good condition?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Work load limit posted on equipment and attachments?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Work load limit, including configuration considerations, not exceeded?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Load movement may occur out of sight or with limited visibility? spotter / signaling person required

  Safe

  At Risk

  Unsafe

  Not Applicable

• Loads lifted over persons, close proximity to obstacles incl. overhead power lines? --not permitted

  Safe

  At Risk

  Unsafe

  Not Applicable

• Crane lift study and permit completed and communicated?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

Excavation

• Is any excavation being performed or in close vicinity?

  Yes

  No

  N/A

• Utilities / telecom called to verify location if digging, open areas, trenches, or disturbed ground?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Approved sub-contractor completed risk assessment, implemented controls and communicated to employees affected?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Design excavation and controls reviewed and signed off on?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Excavation equipment inspected, in good condition, operator trained and current and appropriate for task?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Employees working in vicinity prevented from entering area?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Scaffolds

• Any scaffolds being built, standing or being removed?

  Yes

  No

  N/A

• Licensed engineer designed and licensed person erecting scaffold?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Scaffold Work Load Limit visible and not exceeded? (tools, stored materials, number of persons)<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Safe and complete scaffold (certified)?<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Inspection protocol for scaffold in place and implemented?<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Incompatible scaffold components?<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Emergency Response

• Work at height (incl. roof), elevated work platforms, electrical work, hot work, line breaking, cranes, excavation, or confined space entry taking place?

  Yes

  No

  N/A

• Fire extinguisher (fire blanket, fire watch)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• First Aid Kit and Attendant(s)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Eye-wash station and/or safety shower?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Air horn?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Extraction equipment inspected, readily available, and rescuers competent?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Air monitoring devices?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Respirators readily available, appropriate, and competent person present?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Emergency rescue protocols understood and participants competent and current?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Alarm numbers available and displayed?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Communication devices readily available, functionality tested, communication protocol understood?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Permit conditions met and implemented?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

Driving, Traffic and Interfaces with moving equipment

• Are you driving for work, working alongside or near traffic, or moving heavy equipment with no physical separation (barriers)?

  Yes

  No

  N/A

• Current driver license, vehicle preventive maintenance completed, no known vehicle issues?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Driving required in adverse conditions (rain, hail, snow, high wind, high / low sun, dark, wildlife, high mountain roads, high congestion, after extended shift, winter conditions, remote areas)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Congestion in / near work area or road construction with changing conditions?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Working around operating trains, public transit, ATVs, helicopters/planes, boats / bodies of water?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Traffic control plan in place and implemented?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Hand tools and equipment

• Powered hand tools (electric, pneumatic) to be used?

  Yes

  No

  N/A

• Completed pre-use inspection of tool?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Unsafe or damaged tools or equipment? (including missing or damaged guards)<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Appropriate tools and equipment for job? (e.g. grinding discs for cutting)<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Safe and compatible attachments used with tools and equipment? -guards in place-<br>

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Hot Work, Line Breaking, Confined Spaces

• Hot work will be performed or is performed nearby? -permit

  Yes

  No

  N/A

• Hot work permit completed and controls implemented?

  Yes

  No

  N/A

• Ignition sources eliminated or controlled?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Line breaking? hazardous materials, high temperature, high pressure --permit?

  Yes

  No

  N/A

• Line breaking permit completed and controls implemented?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any confined space entry required?

  Yes

  No

  N/A

• Permit required confined space has completed permit and implemented controls?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Non-permit required: hazards have been identified, risks assessed and controls implemented?

  Yes

  No

  N/A

Ergonomics

• Any awkward body position or tight spaces to perform work?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any excessive reaching required?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any prolonged bending or twisting?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any manual handling of materials / awkward objects >10Kg (22lbs)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any kneeling, squatting or sitting on ground?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any repetitive motion, especially in combination of excessive force?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any work where hands / fingers not in line of sight?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any work above head?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any heavy or awkward lifting (>10Kg / 22lbs)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Environmental Conditions

• Any high temperature and / or in combination with humidity? heat stress risk assessment?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any cold temperature with potential for frostnip or frostbite?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other adverse weather conditions? lightning, flood, hurricane, tornado, snowfall, hail storm, avalanche, mudslide

  Safe

  At Risk

  Unsafe

  Not Applicable

Hazardous Materials: Compressed Gases, Flammable and Combustible Materials, Oxidizing Materials, Poisonous and Infectious Materials, Corrosive Materials, or Dangerously reactive materials.

• Hazardous Materials in use, transported, stored or disposed of?

  Yes

  No

  N/A

• Safety Data Sheets (SDS) readily available and reviewed?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Compressed gasses in use, transported, or stored? -secure, incompatibles segregated, fire-walls

  Safe

  At Risk

  Unsafe

  Not Applicable

• Refrigerant use, transport, storage, removal? License / certification, data logs up-to-date, Safety Data Sheet, secure transport means

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any PCBs, Lead, Asbestos, Carbon Monoxide, Solvents, Welding fumes, Silica, radioactive containing materials that may be damaged or disturbed, etc.?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Waste(s) generated? hazardous --use only company approved hazwaste disposal companies, records, signed

  Safe

  At Risk

  Unsafe

  Not Applicable

• Potential for spills / release of hazardous materials into environment (liquid, gaseous, solid)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

General Conditions

• Slippery / Wet / Uneven Surfaces or Stepping Over/Under Pipes / Facility Infrastructure?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Working in areas requiring access or use of using ladders, steps or stairs etc.? --inspected and tied off, appropriate material--

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any sharp edges or other cut hazards?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Rotating or moving machinery or parts (pulleys, belts, etc.)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Grinding or cutting?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Working in electrically classified area? --explosion proof tools and processes must be implemented--

  Safe

  At Risk

  Unsafe

  Not Applicable

• Low light/glare conditions or areas (in equipment)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Overhead hazards from pipes / ducts / equipment, low or overhanging landings etc.?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Working above or under hazardous processes (high / low temperature, moving parts, hazardous materials, bodies of water, moving equipment, roads, etc.)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Tools / Equipment storage / transport / use: falling from above or falling down below?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Ground or roof openings not barricaded?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Potential for entanglement / engulfment?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Combustible dust (wood, aluminum, grains etc.)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Working alone?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Mechanical hazards?

  Safe

  At Risk

  Unsafe

  Not Applicable

• High or Low pressure?

  Safe

  At Risk

  Unsafe

  Not Applicable

• High or Low temperatures?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Appropriate hand tools (screw-drivers, wrenches, cutting tools, hammers, wire-strippers, etc.)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Other?

  Yes

  No

  N/A

Occupational Health

• Any (hazardous material) exposure hazards absorption / inhalation / ingestion / contact?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any sun, insect, rodent, bacteria, virus, mold, poisonous / wild animals, bodily fluid, sewage, hazards?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Radiation hazards?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Vibration hazards?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Noise hazards?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Splash hazards (chemical)?

  Safe

  At Risk

  Unsafe

  Not Applicable

Human Factors

• Any confusion on how to perform the task at hand?

  Safe

  At Risk

  Unsafe

  Not Applicable

• First time performing task or performing diagnostics / troubleshooting?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Returning to work after multiple days off?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Time pressured?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Excessive distractions?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any lack of procedure / knowledge of process, equipment, tools on work activities to be performed?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any tool / equipment you have not used before or have not been trained to use?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any tool / PPE / equipment / Lock Tag Kit / Emergency Response Equipment that is not readily available / not in good condition / not appropriate size / not appropriate for the task?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any hazards created and not well controlled by other people working in the area (non-company)?

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any continuous work hours in excess of 12 hours? -fatigue assessment-

  Safe

  At Risk

  Unsafe

  Not Applicable

• Any other hazards?

  Yes

  No

  N/A

CONTROL MEASURES

• Lock Out Tag Out Kit?

  Yes

  No

  N/A

• Pre-use tool and/or equipment inspection completed and deficiencies corrected?

  Yes

  No

  N/A

• Risk Assessment & Procedure Review with people performing work?

  Yes

  No

  N/A

• Permits completed and communicated?

  Yes

  No

  N/A

• Competent People?

  Yes

  No

  N/A

• Supervision of Sub-contractors and/or Public?

  Yes

  No

  N/A

• Transport tools and appropriate storage of compressed gases and hazardous materials?

  Yes

  No

  N/A

• Spill kit?

  Yes

  No

  N/A

• Secondary containment?

  Yes

  No

  N/A

• Designated Work Areas?

  Yes

  No

  N/A

• Spotters, Signallers?

  Yes

  No

  N/A

• Lighting sources?

  Yes

  No

  N/A

• Signage?

  Yes

  No

  N/A

• Barricades?

  Yes

  No

  N/A

• Fire Extinguishers?

  Yes

  No

  N/A

• Fire Blankets?

  Yes

  No

  N/A

• Rescue Equipment?

  Yes

  No

  N/A

• UV, Insect Protection?

  Yes

  No

  N/A

• Gas Detection Devices?

  Yes

  No

  N/A

• Spark-proof or explosion proof tools?

  Yes

  No

  N/A

• Safety Data Sheet Review?

  Yes

  No

  N/A

• House Keeping?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

Personal Protective Equipment

• Hand Protection? specify: workgloves, cutproof, electrical, chemical resistant, other?

  Yes

  No

  N/A

• Arm protection? specify: long sleeves, cut-proof sleeves, other?

  Yes

  No

  N/A

• Eye and Face Protection? specify: safety glasses, safety goggles, face-shield with safety glasses, welding hood, other?

  Yes

  No

  N/A

• Foot protection? specify: safety boots, shoes, rubber/chemical resistant boots, other?

  Yes

  No

  N/A

• Head protection? specify: bump cap, hard hat, other?

  Yes

  No

  N/A

• Hearing protection? specify: ear plugs, ear muffs?

  Yes

  No

  N/A

• Fall protection gear? specify: harness, lanyard, SRL, other

  Yes

  No

  N/A

• Respiratory protection? specify: dust mask, half or full face-mask with cartridges, SCBA?

  Yes

  No

  N/A

• Electrical protection? specify: FR clothing layers, suit, gloves, face-shield, etc.?

  Yes

  No

  N/A

• Visibility related gear? specify high-visibility vest, arm/leg reflective bands, other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

Protection Against the Elements

• Adverse weather clothing? specify: raingear, cold-weather gear, etc.

  Yes

  No

  N/A

• Hot or cold temperature kit/gear?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

Verification

• Are all applicable work authorizations / permits appropriately completed, controls implemented, posted and reviewed with our company and sub-contractor employees involved in or affected by the work activities? -complete prior to starting work-

  Yes

  No

  N/A

• Are you performing the work with another employee participating or affected by the work activities?

  Yes

  No

  N/A

• Have you reviewed and discussed all the hazards identified, risks and agreed upon the appropriateness of the controls associated with the work activity? -contact supervisor if disagreement on controls- speak up if you feel not quite right about the approach!

  Yes

  No

  N/A

• Do you have all the appropriate tools, equipment, PPE, and control methods available, put in place and effectively implemented? -if not, address the issues or call supervisor if need supplies or clarification-

  Yes

  No

  N/A

• Are (sub)-contractor employees participating in, affected by, or performing this work activity?

  Yes

  No

  N/A

• A signed and dated (1 year or less) safety declaration is available for each sub-contractor involved in the work activity? --obtain via supervisor if not available-

  Yes

  No

  N/A

• The sub-contractor employees involved in the work have completed training in our company work-related HSE procedures? -complete prior to starting work activity-

  Yes

  No

  N/A

• The sub-contractor employees have taken and fully implemented appropriate measures to control the risks for their and our company employees? -must be done prior to starting work-

  Yes

  No

  N/A

SIGN OFF

• Team Member

  Sign

• Team Member

  Sign

• Team Member

  Sign

• Team Member

  Sign

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

• Team Leader

  Sign

• 2.

  Yes

  No

  N/A