Job Activities

Is a lockout required?

Working on/near live electrical?

Confined space?

Working from heights?

Other activities in area :


Hazards (Enviormental)

Wind Chill

Airborne Particles


Hot/cold surfaces, materials



Heat Stress


Controls used :

Hazards (Body)

Fall Potential

Pinch Point

Electric Shock


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




Are you working alone?

Contact Person :

Phone Number :


Scissor Lift

Personal Basket


Boom-type Lift



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 :

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.