Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Details

  • Location:

  • Activity or task:

  • Photo of job task:

Work Step 1

  • Describe the first step involved in the work

  • Can someone be struck or contacted by anything?

  • Can someone strike against or make contact with any physical hazards.

  • Can someone be exposed to any hazardous conditions?

  • Can someone slip, trip or fall?

  • Can someone fall into anything?

  • Can someone strain or over exert?

  • Can damage to equipment occur?

  • Can someone be caught in anything?

  • Can someone injure someone else?

  • Risk level

  • Safety controls for this step

Work Step 2

  • Describe the next step involved in the work

  • Can someone be struck or contacted by anything?

  • Can someone strike against or make contact with any physical hazards.

  • Can someone be exposed to any hazardous conditions?

  • Can someone slip, trip or fall?

  • Can someone fall into anything?

  • Can someone strain or over exert?

  • Can damage to equipment occur?

  • Can someone be caught in anything?

  • Can someone injure someone else?

  • Risk level

  • Safety controls for this step

Work Step 3

  • Describe the next step involved in the work

  • Can someone be struck or contacted by anything?

  • Can someone strike against or make contact with any physical hazards.

  • Can someone be exposed to any hazardous conditions?

  • Can someone slip, trip or fall?

  • Can someone fall into anything?

  • Can someone strain or over exert?

  • Can damage to equipment occur?

  • Can someone be caught in anything?

  • Can someone injure someone else?

  • Risk level

  • Safety controls for this step

Work Step 4

  • Describe the next step involved in the work

  • Can someone be struck or contacted by anything?

  • Can someone strike against or make contact with any physical hazards.

  • Can someone be exposed to any hazardous conditions?

  • Can someone slip, trip or fall?

  • Can someone fall into anything?

  • Can someone strain or over exert?

  • Can damage to equipment occur?

  • Can someone be caught in anything?

  • Can someone injure someone else?

  • Risk level

  • Safety controls for this step

Work Step 5

  • Describe the next step involved in the work

  • Can someone be struck or contacted by anything?

  • Can someone strike against or make contact with any physical hazards.

  • Can someone be exposed to any hazardous conditions?

  • Can someone slip, trip or fall?

  • Can someone fall into anything?

  • Can someone strain or over exert?

  • Can damage to equipment occur?

  • Can someone be caught in anything?

  • Can someone injure someone else?

  • Risk level

  • Safety controls for this step

RISK GUIDE

Likelihood

  • A - ALMOST CERTAIN - Is expected to occur in most circumstances

  • B - LIKELY - Will probably occur in most circumstances

  • C - POSSIBLE - Might occur at some time

  • D - UNLIKELY - Could occur at some time

  • E - RARE - May occur only in exceptional circumstances

CONSEQUENCES

  • 1 - INSIGNIFICANT - No injuries

  • 2 - MINOR - First aid treatment, any spills contained on site

  • 3 - MODERATE - Medical treatment required, spills contained on site but with outside help

  • 4 - MAJOR - Extensive injuries, loss of production

  • 5 - CATASTROPHIC - Death, toxic chemicals released

RISK LEVEL

  • CONSEQUENCES

  • LIKELIHOOD INSIGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC

  • A (almost certain) H H E E E

  • B (likely) M H H E E

  • C (possible) L M H E E

  • D (unlikely) L L M H E

  • E (rare) L L M H H

E = EXTREME RISK H = HIGH RISK M = MODERATE RISK L = LOW RISK

STAFF & CONTRACTORS (Personnel below have been made aware and understand the procedure, hazards and control measures above)

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

APPROVED BY

  • Add signature

  • Select date

  • 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.