Title Page
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Conducted on
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Prepared by
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Location
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Project Description/Scope of Work
Task Steps, Hazards and Controls, and Personal Protective Equipment
- Task Steps, Hazards and Controls
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Step Description
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Tools/Equipment Needed
- Sawzall/Blades
- Portable Grinder/Blades
- J Hook (Grates)
- Sledgehammer
- Jack Hammer
- Pry Bar
- C Clamps
- Vice Clamps
- Extension Cords
- Tool Batteries/Chargers
- Forklift
- Forklift Conveyor Tool
- Furniture Dolly
- Pallet Jack
- Level
- Cutting Torch/Gas
- Chop Saw/Blades
- Table Saw/Blades
- Tape Measures
- Mig Welders/Gas
- Wire Feed for Welder
- Mig Tip Components
- Bottle Jack
- Hydraulic Splitter
- Plumb Bob
- 1/2" Poly Tubing
- 3/8" Poly Tubing
- Ratchet Straps
- Unistrut
- Lockout Devices and Tags
- Come-Along
- Other
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List other tools required:
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Step Hazards
- Airborne Particles
- Chemical Exposure
- Noise
- Crushing
- Pinching
- Hot Work
- Forklift Operations
- Lifting related injuries
- Slips, trips, falls
- Lacerations
- Puncture
- Struck-by Injuries
- Caught-in/between Injuries
- Electrical Shock/Other Injuries Related to Energized Equipment
- Repetitive Motion
- Vibration
- Other
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Has each employee who plans to operate a forklift been certified to do so through formal classroom and hands-on training, and been observed demonstrating desired forklift operations at this site by an authorized forklift trainer?
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Have you completed a Hot Work Permit?
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List other potential hazards
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Has all energized equipment (Conveyor, brushes, other tunnel equipment, etc.) been de-energized, locked and tagged out according to written LOTO procedures, with this being recorded on a LOTO log?
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Controls
- Lockout/Tagout
- Prohibiting Vehicle Access
- Prohibiting Pedestrian Access
- Ventilation
- Hot Work Permit
- Mechanical Aides (Dollies, Carts, Pallet Jacks, etc.)
- PPE
- Other
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Personal Protective Equipment
- Nitrile Gloves
- Non-slip Shoes
- Welder's Gloves
- Mechanic's Gloves
- Chemical Goggles
- Safety Glasses
- Face Shield
- Welder's Helmet
- Welder's Goggles
- Dust Mask
- Hearing Protection
- Safety-Toed Shoes
- Hard Hat
- Reflective Vest
- Knee Pads
- Tyvek Suit
- Other
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List other PPE required:
