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Title Page
Site conducted
Date
Supervisor Name
Associate Name and IM ID #
Hazard Location
Hazard Class
Class “A”: items will most likely cause permanent disability or loss of life. Class “B”: items will likely cause serious injury or illness resulting in temporary disability. Class “C”: items are likely to cause minor non-disabling injury or illness.
Identified hazard type, and rating (Pareto 1)
Slips, Trip and Fall Hazard e.g. uneven floor surfaces, wet floors, loose cables, debris, etc.
Electrical Hazard e.g. frayed electrical cord, power bar plugged into another power bar, etc.
Fire Hazard e.g. housekeeping, blocked emergency pathways and fire safety equipment, etc.
Physical Hazard e.g. unguarded machinery, exposed moving parts, vibrations.
Other hazards in the work environment i.e. chemical leaks, gas leaks, blood, bodily fluid, etc.
Details Plus Photo (Pareto 2)
Uneven Floor Surfaces
Wet or Slippery Floor
Loose Cables Across Walkway
Debris On Floor
Obstructed Walkway
Damaged Ladder/Stool
Damaged Handrails/Guardrail
Congestion/Clutter
Line Demarcation/Signage/Stop Signs
Details Plus Photo (Pareto 2)
Frayed Wiring
Power bar plugged into another power bar
Damaged housing
Exposed wires
Partially unplugged or missing prongs
Details Plus Photo (Pareto 2)
Blocked emergency exits
Blocked emergency equipment (Fire Extinguisher or Hose)
Heat gun left on or improper position
Details Plus Photo (Pareto 2)
Unguarded machinery
Exposed moving parts
Excess Vibrations
Excess Noise
Poor Lighting
Broken Pallet/Exposed nails
Damaged Racking/Mesh Deck
Unkept Shrink Wrap
Unkept Strapping
Unstable Loads/Product (e.g. Face Picking, leaning, Etc.)
Excessive Dust
Excessive Garbage
Line painting/demarcations
Details Plus Photo (Pareto 2)
kelsay.reed@ingrammicro.com
IM SAFE - Hazard Recognition
Assoicate Hazard Recognition Program recognize associates' contribution to identifying and correcting hazards in the workplace.
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions.
The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction.
You should independently determine whether the template is suitable for your circumstances.
