KNS FLRA

• Document No.

• Employee Name

• Site

• Task

• Conducted on

  Date
• Location
  Address

• Personnel for group FLRA:

Questions:

• Signed in at Administration?

  Yes

  No

  N/A

• Clear entrance to workplace?

  Yes

  No

  N/A

• Is workplace in good order and safe?

  Safe

  At Risk

  N/A

• Is equipment in good order?

  Good Order

  Damaged

• Are employees working properly?

  Yes

  No

  N/A

• Do an act of safety or health:

• Can and will I work safely today?

  Yes

  No

  N/A

• Please check all work areas you will be active in today:

• Open Pit

• Underground

• Process Areas

• Truck Shop

• Mill

• Lab

• Tailings

• Other:

• Please list locations:

• FLRA is a Field Level Risk Assessment, and its purpose is to critically analyze the task being performed beforehand to identify and mitigate risks in the work procedure.

• What am I doing?

• What could go wrong?

• How can it affect people or the planet?

• How likely is it to happen? (0 - Unlikely, 10 - Certain)

• Can this risk be mitigated?

  Yes

  No

  N/A

• Do I feel safe performing this job?

  Safe

  At Risk

  N/A

• If you don't feel safe performing the work, stop and contact your supervisor.

• What will I or we do about it?

• I will work safely today for:

• Date and time:

  Date

• Signature of person completing form:

  Sign