Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Situational Awareness - Focus on your surroundings

  • Ready to perform this job safely?

  • Mind on task?

  • Is this a rush job? If so, slow down.

  • Is other work being conducted nearby?

  • Is your balance, traction, or grip compromised?

  • Are you working in a cramped or awkward position?

  • Are you working in the line of FIRE?

  • Is there time to complete this job on this shift?

  • Has the job carried over from the previous shift? Has the work been coordinated with the previous shift?

Formulate the Plan

  • Is there a JSA available? If so, use it and edit as needed.

  • Any special instructions/training required?

  • Enter special instructions/Training required.

  • What individuals or departments need to be notified?

  • List department or individual that need to be notified.

  • Any special tools or equipment needed?

  • List special tools or equipment needed.

  • Is there a need to interact with subject experts, contractors, etc.?

  • List whom you you need to interact with.

  • Any equipment drawings, operations or maintenance manuals available? If so, retrieve the manuals.

  • Are EHS permits needed? <br><br>(Elevated Work, Confined Spaces, Electrical, Explosives, Hot Work)

  • List permits needed.

  • Are there specifications or tolerances required?

  • List specifications and/or tolerances.

  • Any testing requirements needed?

  • List testing equipment that is required.

  • Stretch if you will be lifting/bending.

Significant Steps to Complete the Task

  • List significant step to complete task

  • Step
  • List significant step to complete task, possible risk(s) with step and protective measure(s) to reduce risk(s)

Assess the Risks

  • Frequency of Task <br><br><br><br>1 - Issue occurs less than once per year<br><br>2 - Issue occurs 1-2 times per year<br><br>3 - Issue occurs monthly<br><br>4 - Issue occurs weekly<br><br>5 - Issue occurs daily

  • Likelihood of injury <br><br><br><br>1 – Highly unlikely<br><br>2 – Unlikely<br><br>3 – Possible<br><br>4 – Probably<br><br>5 – Highly likely

  • Severity of Injury <br><br><br><br>1 - Injuries include first aid only with no lost time from work<br><br>2 - Injuries include medical treatment but no lost time from work<br><br>3 - Injuries include medical treatment and lost time from work but with a full recovery<br><br>4 - Injuries include medical treatment and lost time from work and some permanent impairment.<br><br>5 - Injuries include major permanent impairment or death<br><br><br><br>Working from Height, Confined Space, Live Electrical, and Permit Work/Licensed (Crane, Explosives, Hot work) automatically receives a 5 for severity<br><br><br><br>

  • Multiply the scores above to calculate the overall score of the risk of this task. (2 x 2 x 3 = 12).

Safety Concerns (Check all that apply)

  • Mobile Equipment/Vehicle

  • Toxic/Hazardous Materials

  • Fumes/Mist/Dust

  • Flammables

  • Rotating parts (machine safeguarding)

  • SDS Review

  • Electrical

  • Lockout/Tagout/Tryout

  • Corrosives/Chemicals

  • Pinch Points

  • Walking/Footing/Working Surfaces

  • Heat/Cold Stress

  • Ergonomics

  • Noise

  • Excessive Force

  • Potential Energy

  • Elevated Work/Fall Protection

  • Rigging/Hoists

  • Material Handling

  • Over Extension

  • Homemade Tools Not Used

  • PLC/Automation

  • Barricades/Covers

  • Ladders

  • Line of Fire

Permits Required On Hand (Permits must be on hand before job is begun) (Check all that Apply)

  • None

  • Confined Space Entry

  • Hot Work (Cutting/Welding)

  • Grating Removal

  • Scaffolding

  • Other

  • Please list other permits required

Environmental Concerns (Check all that Apply)

  • None

  • Atmospheric Discharges

  • Liquid Discharges

  • Spill Potential

  • Weather Conditions

  • Waste Disposal will be Required

  • Recycle of materials

  • Other

  • Please list other requirements needed

Work Practices (Check all that apply)

  • None

  • Back-up Person/Watch

  • Exhaust Ventilation

  • Barricades

  • Hoist Requires Inspection

  • Spill Containment

  • Posting/Warning Signs

  • Other

  • Please list other requirements needed

PPE Required - In addition to standard PPE of Safety Glasses, Hard Hat, and Safety Shoes (Mark yes to all that apply)

  • None

  • Electrical

  • Arc Flash Clothing

  • Chemical Resistant Suit

  • Hearing Protection

  • Ear Muffs

  • Tyvek Suit

  • PPE Inspection/Clean

  • Gloves

  • Goggles

  • Face Shield

  • Half Mask Respirator

  • Dust Mask

  • Powered Air Respirator

  • Fall Protection/Safety Harness

  • Fire Retardant Clothing

  • Welding Blankets/Protective Blankets

  • Other

  • Please list other PPE required

List Tools Required

  • Please list tools required to perform this task

List Materials Required

  • Please list materials required to complete this task

Post Work Questions

  • Have all lockouts been removed and test run of equipment performed?

  • Did you notify management/department that work has been completed?

  • Did you clean-up after you completed your work?

  • Was housekeeping up to standard?

  • Has all paperwork been completed and tuned-in to required departments?

  • Is the work evaluated with all interacting and/or contracted parties (Experts, Contractors, Customers, ect.)?

  • Have improvements been proposed during or after the task to perform same or similar tasks better and safer next time?

  • List the improements

  • Add signature

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