Conducted on
Date
Prepared by
Location
Address
Unsafe Act
Unsafe Condition
Category
Body Location
Tools/Equipment
Procedures & Safe Practices
Personal Protective Equipment
Environment
Subcategory
Select
Line Of Fire
Pinch Points
Eyes On Path
Eyes On Task/Hands
Ascending/Descending
Lifting/Lowering/Twisting
Pushing/Pulling
Overextended/Cramped
Line Of Fire Pinch Points Eyes On Path Eyes On Task/Hands Ascending/Descending Lifting/Lowering/Twisting Pushing/Pulling Overextended/Cramped
Subcategory
Selection/Condition/Use
Safety Guards
Subcategory
Work Permits
EIP/Lockout/Tagout
Confined Space/ Attendant
Barricades
Communications
Subcategory
Select
Head (Hardhat)
Eyes & Face
Hearing
Respiratory
Hand & Glove
Body (Clothing)
Fall (Harness)
Foot (Steel Toe)
Head (Hardhat) Eyes & Face Hearing Respiratory Hand & Glove Body (Clothing) Fall (Harness) Foot (Steel Toe)
Subcategory
Walking/Working Surfaces
Houskeeping
Temperatures Extremes
Lighting
Category
Body Location
Tools/Equipment
Procedures & Safe Practices
Personal Protective Equipment
Environment
Subcategory
Select
Line Of Fire
Pinch Points
Eyes On Path
Eyes On Task/Hands
Ascending/Descending
Lifting/Lowering/Twisting
Pushing/Pulling
Overextended/Cramped
Line Of Fire Pinch Points Eyes On Path Eyes On Task/Hands Ascending/Descending Lifting/Lowering/Twisting Pushing/Pulling Overextended/Cramped
Selection/Condition/Use
Safety Guards
Work Permits
EIP/Lockout/Tagout
Confined Space/ Attendant
Barricades
Communications
Walking/Working Surfaces
Houskeeping
Temperatures Extremes
Lighting
Select
Head (Hardhat)
Eyes & Face
Hearing
Respiratory
Hand & Glove
Body (Clothing)
Fall (Harness)
Foot (Steel Toe)
Head (Hardhat) Eyes & Face Hearing Respiratory Hand & Glove Body (Clothing) Fall (Harness) Foot (Steel Toe)
Severity
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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.