Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Project Title:

  • Location:

  • Date Analysis Completed:

  • Select date

  • Scheduled Start Date:

  • Select date

  • Task Description:

  • Attendees:

  • Prepared By:

  • Step 1. Review the scope of the job, sequence of work and all potential hazards.

    Step 2. Walk-through the work area and point out possible hazards. Make a list of all potential hazards identified and how hazard will be eliminated or controlled. (Identify who is responsible for eliminating or controlling hazard and how it will be handled).

    Step 3. Send an electronic copy of the completed written hazard analysis to the safety department contact BEFORE work begins.

  • New sequence of work
  • Sequence of work

  • Potential Hazards

  • How to eliminate or control

  • SEQUENCE OF WORK. POTENTIAL HAZARDS. ELIMINATE OR CONTROL METHOD

  • Name of preparer:

  • Select date

  • Add signature

  • Safety Representative:

  • Select date

  • Add signature

  • Reviewed by PC (Project.) SO (Maint.)

  • Select date

  • Add signature

  • POTENTIAL HAZARDS AND CONDITIONS ( References in parentheses available on Intranet)

1.0 - WORKER HABITS & ACTIONS:

  • Workers given adequate training for the job?

  • Has provision been made for rotating repetitive tasks?

  • Proper hoisting / lifting techniques used

  • Confined space permits required? (Confined space program)

  • If yes, annotate:

  • Should fire alarm system be disabled? (See 4/21/03 letter)

  • If yes, annotate:

  • Reviewed Volunteer Responsibility with all workers?

  • WORKER HABITS & ACTIONS: Additional Notes:

2.0 BUILDING CONDITION:

  • Any collapse hazard evident?

  • Note all that applies:

  • Are there arrangements in place to keep building secure?

  • If yes, annotate:

  • Is there sufficient lighting for the work?

  • Appropriate building oversight contacted about the work?

  • Demolition procedure reviewed?

  • BUILDING CONDITION: Additional Notes:

3.0 - HEAVY EQUIPMENT:

  • Operators maintaining adequate distance from other workers?

  • Equipment in good repair? Roll-over protection?

  • Ensure daily inspections prior to commencing use.

  • Call before you dig procedures followed?

  • Are trenches properly sloped, shielded and barricaded?

  • Do pre-existing conditions require photography?

  • HEAVY EQUIPMENT: Additional Notes:

4.0 - LOCKOUT / TAGOUT:

  • Training and personal lockout devices needed? (See 8/2/02 letter).

  • If yes, annotate:

  • Blocks for gravity restraint?

  • Pressure lines bled down? Slip blinds? Valve blocks?

  • Circuit breaker lockout?

  • Valve handle removed or chained in off position?

  • Cord & plug under worker control?

  • Are "Out of Use" tags available? (See out of service documentation)

  • LOCKOUT / TAGOUT: Additional Notes:

5.0 - ENVIRONMENT, CHEMICAL, ELECTRICAL:

  • Excessive dust, noise, fumes, heat, vibration?

  • If yes, annotate:

  • Adequate ventilation & illumination?

  • Physical environment in the work area acceptable?

  • Will hazardous substances will be brought on the job site?

  • List applicable substances:

  • All electrical equipment properly grounded?

  • GFCI receptacles available where needed?

  • Are workers familiar with policy on installing natural gas piping? (See 5/24/02 letter).

  • Pressure testing and chemical flushing of pipe installations?

  • Are plywood or plexiglass available to cover unattended electrical panels? (See 3/25/03 letter).

  • ENVIROMENTAL, CHEMICAL, ELECTRICAL: Additional Notes:

6.0 - EQUIPMENT SAFEGUARDING:

  • Are all guards in place? Necessary guards provided and pinch points protected?

  • Compressors and other fixed-place equipment anchored?

  • Equipment safety checked before being put to use?

  • Equipment maintained? All rotating shafts, belts guarded?

  • EQUIPMENT SAFEGUARDING: Additional Notes:

7.0 - INCLEMENT WEATHER:

  • Are weather condition safe for the task being performed? ie; heavy rain, lightning, high winds, ice, snow?

  • INCLEMENT WEATHER: Additional Notes:

8.0 - HAND & POWER TOOLS:

  • Tools and cords in good condition?

  • Tools safety checked before using?

  • Proper tools provided?

  • Welding / Torching in designated areas only?

  • HAND & POWER TOOLS: Additional Notes:

9.0 - HOUSEKEEPING / STORAGE METHODS:

  • Have daily cleanup arrangements been discussed?

  • How will materials be organized and stored?

  • Are the areas free of clutter, dirt and spills?

  • Are aisles, catwalks and walkways well defined and unobstructed? Storage stable? Too high? Unusual congestion?

  • Note all that applies:

  • Pallet storage acceptable?

  • Are items exposed to weather?

  • How will tools and equipment be stored?

  • Note all that applies:

  • HOUSEKEEPING / STORAGE METHODS: Additional Notes:

10.0 - FALL PREVENTION:

  • Can a worker fall from one level to another or on same level?

  • Note all at risk areas:

  • Has document "Working in Elevated Locations" been reviewed with workers?<br>

  • Is there a need for fall protection training / refresher?

  • If yes, annotate:

  • Has Exterior Maintenance been consulted?

  • Are safety lines and harnesses required?

  • If yes, annotate:

  • Is scaffolding needed for the tasks?

  • Note all that applies:

  • Catwalks and elevated walkways in good condition? Handrails sturdy? Guard rails, toe boards in place?

  • Are there dangers for persons below?

  • Note all that applies:

  • Is there a danger from overhead high voltage electrical lines?

  • If yes, annotate:

  • FALL PREVENTION: Additional Notes:

11.0 PERSONAL PROTECTIVE EQUIPMENT:

  • Hard hats? Safety glasses? Work boots? Cotton respirators? Gloves? Protective clothing available? Face shields?

  • Hard hats are to be approved in accordance with current safety requirements, should be free of stickers tags ect.. that do not relate to specific identification or job function, and worn bill forward (with the exception of welding / torching or surveying)

    All high visibility clothing ie. vest, shirts are to be High Visibility Orange or Yellow only

  • Hearing protection worn? Welding helmets? Aprons?

  • Are workers trained and approved to wear respirators? (See Respiratory Protection Program).

  • PERSONAL PROTECTIVE EQUIPMENT: Additional Notes:

12.0 - MATERIALS HANDLING:

  • Are material handlers properly trained?

  • What provisions will be made for securing loads?

  • Note all that applies:

  • Will pallets be required?

  • In good condition?

  • MATERIALS HANDLING: Additional Notes:

13.0 - ENGINEERING / DESIGN:

  • Are there any plans to deviate from AFC prints? If so, has the change been approved by the Engineer?

  • Explain:

  • Has a sketch been provided documenting the change?

  • Are City permits required for the work?

  • If yes, annotate:

  • ENGINEERING / DESIGN: Additional Notes:

14.0 - PERSONAL SAFETY / PASSERBY HAZARDS:

  • Trip hazards? Floor openings covered? Sharp objects? Overhead clearance? Railings? Warning signs?

  • Note all that are applicable:

  • Danger signs needed?

  • If yes, annotate:

  • Flagman needed?

  • If yes, annotate:

  • Area barricaded?

  • If yes, annotate:

  • Anything loose on parapet or ledge?

  • If yes, annotate:

  • Restraining devices required?

  • If yes, annotate:

  • Tie backs in place?

  • Sidewalks and private roadways in good repair?

  • Pedestrians alert to moving vehicles?

  • Can worker be caught in or between objects?

  • If yes, annotate:

  • Will a crane be required? Has master rigger been consulted?

  • If yes, annotate:

  • Are extension cords hoses ect.. routed safely?

  • PERSONAL SAFETY / PASSERBY HAZARDS: Additional Notes:

15.0 - EMERGENCY RESPONSE:

  • Emergency phone numbers posted (on wall and or other known locations) for First Aid, Fire, Chemical, electrical emergency?

  • Do workers know whom to call?

  • Are needed supplies on hand?

  • Posted fire brigade lists up to date? Brigade members know procedures they must follow when activated?

  • Emergency cleanup provision in place for chemical spills?

  • Has emergency evacuation procedure been provided? Are personnel aware of evacuation plan?

  • Are fire extinguishers charged and in good condition?

  • Checked monthly and marked?

  • Is there adequate safe storage for combustibles, rags ect..?

  • Are there possible spontaneous combustion hazards?

  • Are flammable or explosive materials used?

  • Are eye wash stations available?

  • If yes note locations:

  • MSDS accessible?

  • Is emergency plan in place for Refrigerant gas leaks?

  • EMERGENCY RESPONSE: Additional Notes:

16.0 - LADDERS:

  • In good condition?

  • Are ladders designed for anticipated use?

  • Has worker completed ladder safety training? (See 2/20/03 letter).

  • LADDERS: Additional Notes:

17.0 - PERMITS / REPORTS:

  • Confined space?

  • If yes, annotate:

  • Hot work?

  • If yes, annotate:

  • Fire guard report?

  • If yes, annotate:

  • Energized electrical work permit?

  • If yes, annotate:

  • Call before you dig?

  • If yes, annotate:

  • DOB or other permits required?

  • PERMITS / REPORTS: Additional Notes:

18.0 - ACCIDENT PREVENTION PLAN:

  • On large projects has accident prevention plans been reviewed with Crew Overseers, Volunteers? (See 3/25/03 letter).

  • Have workers been informed of Accountability Program?

  • ACCIDENT PREVENTION PLAN: Additional Notes:

19.0 - OVERALL JOB HAZARD ANALYSIS ADDITIONAL NOTES:

  • END

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