Title Page

  • FLHA #

  • Company Name:

  • Site Name:

  • FLHA Date &Time:

  • Prepared by

  • Location
  • Worksite Representative Name & Phone Number

  • PO#(if applicable)

  • Describe the task(s) being performed

  • If working alone, explain check-in procedure:

  • Location of First Aid supplies:

  • Emergency Muster Location:

  • See It.....What could go wrong?

  • Evaluate It.....How bad could it be?

  • Control It.....What can I do to fix it?

  • Worksite Comments and Observations:

Hazards

  • Hazards to Consider- check off all that apply. If you check off a hazard, please choose the Risk Rating and Probability Frequency for that hazard

Hazards-Physical Work Area

  • Housekeeping

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Slip/Trip/Fall potential

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Ground/surface condition

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Blocked exits & walkways

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Open Excavation

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Confined/restricted space

  • Risk Rating

  • Probability Frequency

  • Was a confined Space Permit obtained?

  • How I control the hazard

  • Cramped/tight work area

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Improper ventilation

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Hot work

  • Risk Rating

  • Probability Frequency

  • Was a Hot Work Permit Obtained?

  • How I control the hazard

  • Vehicle/pedestrian traffic

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Working at heights

  • Risk Rating

  • Probability Frequency

  • Do you have a fall arrest plan?

  • Do you have a fall arrest rescue plan?

  • Do you have proper fall arrest equipment?

  • Was the fall arrest equipment inspected?

  • How I control the hazard

  • Falling objects

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards-Electrical

  • Working on/near energized equipment

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Working on/near electricity

  • Risk Rating

  • Probability Frequency

  • Is Lock Out/Tag out required?

  • How I control the hazard

  • Powerlines overhead/ underground

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards- Equipment

  • Incorrect tools/equipment

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Defective tools/equipment

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Unguarded Equipment

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Ladder use

  • Risk Rating

  • Probability Frequency

  • Did you inspect the ladder for defects?

  • Were any defects found during inspection?

  • How I control the hazard

  • Scaffolding

  • Risk Rating

  • Probability Frequency

  • Are the platforms stable?

  • Does the scaffold have any defects?

  • How I control the hazard

  • Loads moving or being hoisted

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Critical Lift

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards-Ergonomic

  • Awkward body positioning

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Overextension

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Vibration

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Repetitive Motion

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Forceful Pushing/Pulling

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Awkward grip/load carried

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Working at over head height

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Twisting/reaching/bending

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards- Hazardous Substances

  • Chemicals

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Spill potential

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Dust/fumes/vapours/gases

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Fire/explosion/reactive properties

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Acid/corrosive material

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Aerosols

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Material storage & handling

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards-Biological

  • Blood/bodily fluids

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Virus/bacteria

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Waste disposal

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Lack of hygiene/sanitation

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards-Work Environment

  • Noise

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Wildlife

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Insects/bites

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Remote work location

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Weather

  • Risk Rating

  • Probability Frequency

  • Type of weather risk

  • How I control the hazard

  • Lighting

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Stress/fatigue

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Hazards-People & Personal

  • Violence

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Harassment

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Mental Health & Stability

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Age

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Personal limitations

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Illness

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Working alone

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Others working below/overhead

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Other trades working in the area

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

  • Workers not competent

  • Risk Rating

  • Probability Frequency

  • How I control the hazard

Procedures

  • Did you properly lock out & tag any defective tools/equipment or energy sources?

  • Did you notify nearby workers of any hazards that may affect them?

  • Did you correct any Health and Safety hazards that you identified? This can be done by eliminating the hazard, PPE, etc.

Personal Protective Equipment (PPE)

  • PPE Required:

  • Safety Glasses

  • Hearing Protection

  • Hard Hat

  • Gloves

  • Specialty PPE

  • If specialty PPE required, please specify.

  • PPE Inspected?

After Shift/Job Sign Off

  • Was the work area cleaned up/materials store and disposed of properly?

  • Did any incidents occur?

  • If yes, explain:

WORKER NAME (print)

  • Print

  • SIGNATURE

  • Date & Time

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.