Information

  • Client / Site

  • Work Order No.

  • Location
  • Supervisor

  • Conducted on

  • Job Description:

  • Prepared by

  • Personnel

  • Tap to enter information

  • Tap to enter information

  • Tap to enter information

  • Tap to enter information

Job Activities

  • Is a lockout required?

  • Working on/near live electrical?

  • Confined space?

  • Working from heights?

  • Other activities in area :

Hazards

Hazards (Enviormental)

  • Wind Chill

  • Airborne Particles

  • Vapours

  • Hot/cold surfaces, materials

  • Noise

  • Lighting

  • Heat Stress

  • Wind

  • Controls used :

Hazards (Body)

  • Fall Potential

  • Pinch Point

  • Electric Shock

  • Housekeeping

  • Slip - Trip

  • Flying Particles

  • Thermal Burn

  • Manual Lifting KG

  • Sharp Objects

  • Work Over Head

  • Falling Objects

  • Proper Positioning

Hazards (Chemical)

  • Chemicals Identified

  • MSDS Reviewed

  • System Under Pressure

  • Chemical Burn

  • Skin/Eye Irritation

  • Inhalation

  • Radiation

Communications

  • Are you working alone?

  • Contact Person :

  • Phone Number :

Equipment

  • Scissor Lift

  • Personal Basket

  • Forklift

  • Boom-type Lift

  • Crane

  • Chainfall

  • Is the equipment in good condition?

  • Do you have the proper rigging?

  • Have you done an inspection of the surrounding area?

  • Are the hand tools in good condition?

  • Is the scaffold in good condition?

  • Is the ladder in good condition?

  • Is the ladder secure?

  • Do I have the right ladder for the job?

Safety Barriers

  • Fixed Barricades (used if tape has potential to become damaged)

  • (Tape) Danger (used to keep people out)

  • (Tape) Caution (used to alert people to hazards)

  • Barricade Tags (required with barricades)

  • Are signs of warning required?

  • Are holes covered?

  • Are handrails in good condition?

Emergency Equipment

  • Is a fire extinguisher required?

  • Safety shower # :

  • Eyewash # :

  • Muster point :

  • Closest Door # :

  • ERT contact (confined space) :

  • Comments :

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.