KBA Prestart Risk Assessment

• Job #

• Conducted on

  Date

• Prepared by

• Address
  Address

• Proposed work description

• Instructions
  -------------------------
  1. Answer "Safe", "At Risk", "N/A" for each of the hazards below
  2. If "At Risk", follow the questions to identify the likelihood of occurrence, severity and risk rating
  3. Include any notes and photos by clicking on the paperclip icon and then "Add Image"
  4. Answer the relevant control questions
  5. Complete the form by providing the relevant signatures

Confined Space

• Confined Space

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Confined Space permit received

  Yes

  No

  N/A

• Enter description of control measures

Working at Height

• Working at Height

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Working at height permit received

  Yes

  No

  N/A

• Height safety harness worn

  Yes

  No

  N/A

• Enter description of control measures

Restricted Access

• Restricted Access

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Electricity

• Electricity

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Compressed Air

• Compressed Air

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Uneven/slippery Surfaces

• Uneven/slippery Surfaces

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Hazardous Gases

• Hazardous Gases

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Asbestos

• Asbestos

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Vehicular movement

• Vehicular movement

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Dust & Airborne particle's

• Dust & Airborne particle's

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Working over/near water

• Working over/near water

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Overhead hazards

• Overhead hazards

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Manual handling

• Manual handling

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Fire / Explosion

• Fire / Explosion

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Noise

• Noise

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

UV

• UV

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Underground / Concealed services

• Buried/Covered services

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Lone worker

• Lone worker

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Spills / Pollution

• Spills / Pollution

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Completion

• Observations and recommendations

• Work completed

  Yes

  No

  N/A

• Equipment is safe & fit to operate

  Yes

  No

  N/A

• Customer representative

  Sign