MRP - FLHA Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Company or Contractor Name

  Select

• Lead or Supervisor Name

• Lead or Supervisor Phone #

• Work(s) Outline for the Day

SCOPE OF WORK

• Describe the scope of work(s) to be completed

• Location of First Aid Supplies:

• Emergency Muster Location(s):

• If Working Alone, Explain Check-In Procedure:

  Yes

  No

  N/A

• What is the Check-In Procedure:

HAZARD ASSESSMENT

• Physical

  Select Housekeeping Material Storage & Handling Slip/Trip/Fall Potential Blocked Exits & Walkways Confined / Restricted Space Improper Ventilation Powerlines Overhead / Underground Ground / Surface Condition Open Excavation Lighting Weather Hot Work Vehicle / Pedestrian Traffic Working at Heights Scaffolding Falling Objects Loads Moving or Being Hoisted Ladder Use Critical Lift Others Working Below / Overhead Incorrect Tools / Equipment Working on / Near Energized Equipment Defective Tools/Equipment Noise Vibration Other

  • Housekeeping
  • Material Storage & Handling
  • Slip/Trip/Fall Potential
  • Blocked Exits & Walkways
  • Confined / Restricted Space
  • Improper Ventilation
  • Powerlines Overhead / Underground
  • Ground / Surface Condition
  • Open Excavation
  • Lighting
  • Weather
  • Hot Work
  • Vehicle / Pedestrian Traffic
  • Working at Heights
  • Scaffolding
  • Falling Objects
  • Loads Moving or Being Hoisted
  • Ladder Use
  • Critical Lift
  • Others Working Below / Overhead
  • Incorrect Tools / Equipment
  • Working on / Near Energized Equipment
  • Defective Tools/Equipment
  • Noise
  • Vibration
  • Other

• Ergonomic

  Select Awkward Body Positioning Overextension Repetitive Motion Twisting / Reaching / Bending Cramped / Tight Work Area Forceful Pushing / Pulling Awkward Grip / Load Carried Awkward Grip / Load Carried Other

  • Awkward Body Positioning
  • Overextension
  • Repetitive Motion
  • Twisting / Reaching / Bending
  • Cramped / Tight Work Area
  • Forceful Pushing / Pulling
  • Awkward Grip / Load Carried
  • Awkward Grip / Load Carried
  • Other

• Chemical

  Select Freeze Burn Chemical Handling / Storage Spill Potential Dust / Fumes / Vapors / Gases Fire/Explosion/Reactive Properties Acid / Corrosive Material Aerosols Other

  • Freeze Burn
  • Chemical Handling / Storage
  • Spill Potential
  • Dust / Fumes / Vapors / Gases
  • Fire/Explosion/Reactive Properties
  • Acid / Corrosive Material
  • Aerosols
  • Other

• Biological

  Select Waste Disposal Blood / Bodily Fluid Virus / Bacteria Insect Bite Lack of Hygiene / Sanitation Other

  • Waste Disposal
  • Blood / Bodily Fluid
  • Virus / Bacteria
  • Insect Bite
  • Lack of Hygiene / Sanitation
  • Other

• Psychosocial

  Select Personal Limitations / Illness, Age, Mental Stability Harassment / Violence Stress / Fatigue Working Alone Worker(s) NOT Competent

  • Personal Limitations / Illness, Age, Mental Stability
  • Harassment / Violence
  • Stress / Fatigue
  • Working Alone
  • Worker(s) NOT Competent

• Critical Hazards

  Select

• Are Workers Fit for Duty

  Yes

  No

  N/A
WORKER NAME

• Worker Name

• Reason

• If NOT Fit for Duty – Report to Supervisor

PERSONAL PROTECTIVE EQUIPMENT

• List of PPE Required

  Select

• PPE Inspected

  Yes

  No

  N/A

HAZARDS - Identify and Outline Plans to Eliminate and/or Control Each Hazard

LOCKOUT - TAG OUT

• Did you Properly Lock Out / Tag Out ANY Defective Equipment?

  Yes

  No

  N/A

• What was the equipment?

• Did you Notify Nearby Workers of ANY Hazards that may Affect Them?

  Yes

  No

  N/A

• Who did you notify?

• What was the hazard that may affect them?

HAZARD TASKS

• Tap ( + ) to add a Task

Choose a Task

• Task

  Select

FABRICATION - Identify the hazards and controls

• Fabrication Tasks

  Select

Fabrication - Hazards and Controls

• Fabrication Hazards

  Select

• Fabrication Controls

  Select

• Hazard Priority

  Select A - High (Immediate danger to life) B - Moderate (High danger to life) C - Low (Low danger to life)

  • A - High (Immediate danger to life)
  • B - Moderate (High danger to life)
  • C - Low (Low danger to life)

• Hazard Frequency

  1 - Frequent (Happens daily)

  2 - Regular (Every few days)

  3 - Rarely (Every few weeks)

• Initial

  Sign

INSTALLATION - Identify the hazards and controls

• Installation Tasks

  Select

Installation - Hazards and Controls

• Installation Hazards

  Select

• Installation Controls

  Select

• Hazard Priority

  Select A - High (Immediate danger to life) B - Moderate (High danger to life) C - Low (Low danger to life)

  • A - High (Immediate danger to life)
  • B - Moderate (High danger to life)
  • C - Low (Low danger to life)

• Hazard Frequency

  1 - Frequent (Happens daily)

  2 - Regular (Every few days)

  3 - Rarely (Every few weeks)

• Initial

  Sign

LAYOUT - Identify the hazards and controls

• Layout Tasks

  Select

Hazards and Controls

• Layout Hazards

  Select

• Layout Controls

  Select

• Hazard Priority

  Select A - High (Immediate danger to life) B - Moderate (High danger to life) C - Low (Low danger to life)

  • A - High (Immediate danger to life)
  • B - Moderate (High danger to life)
  • C - Low (Low danger to life)

• Hazard Frequency

  1 - Frequent (Happens daily)

  2 - Regular (Every few days)

  3 - Rarely (Every few weeks)

• Initial

  Sign

PRESSURIZNG - Identify the hazards and controls

• Pressurizing Task

  Select

Pressurizing Hazards and Controls

• Pressurizing Hazards

  Select

• Pressurizing Controls

  Select

• Hazard Priority

  Select A - High (Immediate danger to life) B - Moderate (High danger to life) C - Low (Low danger to life)

  • A - High (Immediate danger to life)
  • B - Moderate (High danger to life)
  • C - Low (Low danger to life)

• Hazard Frequency

  1 - Frequent (Happens daily)

  2 - Regular (Every few days)

  3 - Rarely (Every few weeks)

• Initial

  Sign

GROUND WORKS - Identify the hazards and controls

• Ground Works Tasks

  Select

Ground Works Hazards and Controls

• Ground Works Hazards

  Select

• Ground Works Controls

  Select

• Hazard Priority

  Select A - High (Immediate danger to life) B - Moderate (High danger to life) C - Low (Low danger to life)

  • A - High (Immediate danger to life)
  • B - Moderate (High danger to life)
  • C - Low (Low danger to life)

• Hazard Frequency

  1 - Frequent (Happens daily)

  2 - Regular (Every few days)

  3 - Rarely (Every few weeks)

• Initial

  Sign

HOUSE KEEPING - Identify the hazards and controls

• House Keeping Tasks

  Select

House Keeping Hazards and Controls

• House Keeping Hazards

  Select

• House Keeping Controls

  Select

• Hazard Priority

  Select A - High (Immediate danger to life) B - Moderate (High danger to life) C - Low (Low danger to life)

  • A - High (Immediate danger to life)
  • B - Moderate (High danger to life)
  • C - Low (Low danger to life)

• Hazard Frequency

  1 - Frequent (Happens daily)

  2 - Regular (Every few days)

  3 - Rarely (Every few weeks)

• Initial

  Sign

WORKER SIGN OFF - Review hazards with workers prior to commencement of work

• Tap + to add worker

Worker

• Worker Name & Signature/Initial

  Sign

• Date and Time

  Date

• NOTE: If leaving and coming back to a task, workers must record the time and initial, acknowledging that no new hazards are present.

• Sent to Supervisor and Worksite Representative for Approval

  Yes

  No

  N/A

ALL AFFECTED WORKSITE PARTIES MUST SIGN OFF BEFORE WORK CAN BEGIN