Title Page

  • Name of Lone Worker

  • Department

  • Conducted on

  • Location
  • Prepared by

General Details

  • Description of task/s involved

Hazards and Risks

  • Click + to add hazards identified

  • Hazard
  • Identify type of hazard

  • Description of observed risk

  • Does this hazard hinder you from finishing your work alone?


  • Upon evaluating all hazards before commencing work, rate the overall safety of the workplace

  • Full Name and Signature of Lone Worker

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.