Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

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  • Critical Controls: Actions and conditions that must be in place and functioning 100% of the time, without fail, to protect people when working in potentially significant risk situations.

    Instructions: For each critical control, select Controlled, At Risk, or NA (Not Applicable or Not Observed). See the Assessment below for definitions. If something is marked At Risk, immediately Pause the work until the missing protections are put in place. Write the corrective action taken in the notes box below

  • Critical Controls

  • Have you completed a Team Risk Assessment prior to starting the job?

  • The guards protect the employee from moving parts, rotating equipment, pinch points, line of fire, or are guarded by location

  • If rotating parts are not isolated, ensure that barricades, signage, or guards are in place

  • If machine guards are being removed, ensure the equipment is in a zeroenergy state

  • Employee understands which emergency stop devices are on the equipment, how they function, and how to activate the emergency stop function

  • Employee is dressed in clothing that is not loose fitting and long hair is tied back or protected

Assessment

  • CONTROLLED The presence of this control is verified and effective

  • AT RISK This control is missing or ineffective

  • NA / NO Not Applicable to this exposure situation or Not Observed

Notes

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.