Information
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Document No.
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Job Number
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Conducted on
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Location
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Personnel
Check:
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Are all energy sources isolated?
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Does machinery have guarding?
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Is this task safe from a fall from height?
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Is it clear from people above or below?
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Are the tools right for the job?
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Are tools in safe working condition?
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Is my task free from hurting others?
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Is it free from possibility of sustaining a strain or sprain?
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Is it free from confined space work?
Am I free from exposure to:
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Am I free from exposure to:
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Noise
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Hazardous substances
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Thermal stress (heat/cold)
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Vibration / radiation
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Gas / fumes / dust
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Moving traffic
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Working with suspended load
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Have the hazards identified been controlled?
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Insert Signature
