Title Page

  • Conducted on

  • Client / Site

  • Non Routine Task Review for

  • Personnel working on this Job or task

  • Prepared by

Management of Change

  • Are you making any changes to:

  • Are you making any modifications, replacements, or additions that are not identical in configuration, fit, or function to original design or conditions?

  • If any questions above answered with “Yes”, please: STOP WORK, Contact a supervisor and reference EHS-GEN-11, to proceed with the Management of Change process.

  • Does the change create safety concerns upstream of the process?

  • If any questions above answered with “Yes”, please: STOP WORK, Contact a supervisor and reference EHS-GEN-11, to proceed with the Management of Change process.

  • Does the change create safety concerns downstream the process?

  • If any questions above answered with “Yes”, please: STOP WORK, Contact a supervisor and reference EHS-GEN-11, to proceed with the Management of Change process.

Situational Awareness – These situations can lead to injuries or loss. STOP WORK if these conditions arise or change and address them in the Job Plan on the next page.

  • Does anyone on team need training on equipment or tools or task?

  • Will you be working/traveling through an area with mobile equipment?

  • Do you need to notify other departments of work being done?

  • Changing weather conditions?

  • Is other work being conducted Above/Below/Nearby you?

  • Will your work affect anyone/anything other than you?

  • Has job carried over from previous shift?

  • Have you checked the area for snakes, scorpions, bees, wasps, or other insects?

Safety Concerns (Check all that apply) If you check a box below. how will you address it?

  • Mobile Equipment / Vehicle / Traffic

  • Toxic/Hazardous Materials / Corrosive Chemicals

  • Fumes/Mist/Dust

  • Flammables / Fires

  • Rush Job

  • Other EHS Permits Needed

  • Rotating Parts (Machine / Safeguard)

  • SDS Review

  • Electrical (incl. overhead supply)

  • Lockout / Tag out / Tryout

  • Equipment drawings and/or maintenance manuals

  • Balance & Traction

  • Testing Requirements

  • Pinch Points

  • Walking / Footing Working Surface

  • Heat / Cold Stress

  • Confined Space

  • Noise

  • Ergonomics / Awkward Positions

  • Line of FIRE

  • Waste Disposal / Recycling of Materials

  • Potential Energy

  • Elevated Work/Fall Protection

  • Rigging / Hoists

  • Material Handling

  • Excessive Force / Over-extension

  • Communications with Contractors

  • Environmental Spills / Discharges

  • Homemade tools

  • PLC/Automation

  • Barricades / Covers

  • Ladders

  • Stretching Lifting Bending

  • Not enough time to complete the job

  • Other

List Tools & Materials Required

  • Please list tools required to perform this task

Assess the Risks

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

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

  • Severity of Injury <br> <br>1 - Injuries include first aid only with no lost time from work <br>2 - Injuries include medical treatment but no lost time from work <br>3 - Injuries include medical treatment and lost time from work but with a full recovery <br>4 - Injuries include medical treatment and lost time from work and some permanent impairment. <br>5 - Injuries include major permanent impairment or death <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>

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

Job Plan, Enter 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)

Post Work Questions

  • Has all equipment been restored to original running condition?

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

  • Were there any Housekeeping issues?

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

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

  • Has the work been evaluated with all interacting / contracted parties (experts, contractors, customers, etc.)?

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

  • List the improvements

  • Add signature

Authorization to Proceed with MOC

  • Add signature

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.