Lone Worker Hazard Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

The Lone Worker

• Does the worker have direct supervision by his or her employer, or another person designated as a supervisor, at any time?

  Yes

  No

  N/A

• Is the lone worker sufficiently experienced for the task?

  Yes

  No

  N/A

• Is the lone worker provided with training that allows the equipment, substances, or personal protective equipment to be used safely?

  Yes

  No

  N/A

• Is the lone worker provided with information about the risks involved with the task and the precautions to be taken?

  Yes

  No

  N/A

• Does the lone worker have any known medical conditions that make them unsuitable for working alone?

  No

  Yes

• What shift is the worker assigned to?

Work Area

• Will the worker be in a secured or unsecured area? (For example, is a badge required to access certain areas? Or is a door left unlocked or propped open in a given area?)

  Secure

  Non-secure

• Is there safe access and egress?

  Yes

  No, lone worker not permitted

  Not Applicable

• Can a lone worker safely operate the equipment/machinery required to be used?

  Yes

  No, lone worker not permitted

  Not Applicable

• Can all substances and hazardous materials be safely handled by a lone worker?

  Yes

  No, lone worker not permitted

  Not Applicable

• Is the worker exposed to the public?

  No

  Yes

• Can manual material handling, where required, be carried out safely by a lone worker? (For example, if company policy states you cannot manually lift more than 50 lbs and the job requires a manual lift of 75 lbs a lone worker is not permitted.)

  Yes

  No, lone worker not permitted

  Not Applicable

• Has any risk of violence been addressed? (Consider any threats that have been made such as, a terror threat level, domestic, protesters, co-workers, animals or insects and public.)

  Yes

  No

  N/A

• Will the lone worker be exposed to extreme temperatures?

  No

  Yes

Communication and Supervision

• Are there arrangements for regular contact between the lone worker and supervisor/employer?

  Yes

  No

  N/A

• Are supervisors able to periodically visit and observe the lone worker?

  Yes

  No

  N/A

• Is there access at all times to communicate with the "outside world" and emergency services?

  Yes

  No

  N/A

• Are automatic monitoring and warning devices appropriate for the situation?

  Yes

  No

  N/A

• Is there a JSA or JHA for the task?

  Yes

  No

  N/A

Emergency Management

• Is the lone worker trained in first aid?

  Yes

  No

  N/A

• Are adequate first aid facilities available?

  Yes

  No

  N/A

• In an emergency can Emergency Management Services locate and reach the lone worker?

  Yes

  No

  N/A

• Are alarm systems in working order? (Such as fire alarms, security system alarms, carbon monoxide alarms or weather related notification.)

  Yes

  No

  N/A

• Is there an emergency action plan (EAP) in place for the site?

  Yes

  No

  N/A

• Does the EAP address lone workers?

  Yes

  No

  N/A

Description of activity or task being assessed.

Significant Hazards

• Refer to the Hazard Assessment and enter hazards for any question answered "No."

Current Control Measures

• List current controls in place.

• With the current controls in place, the risk is:

  Unacceptable

  Further Controls Required

  Adequately Controlled

• Further assessment is required.

• Additional controls are required prior to lone worker activities.

Action Required

• List further action needed to adequately control risks

• Enter date of completion

  Date

• Signature of personnel completing the action plan.

  Sign