Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Risk Assessment & Tailboard
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Date & Time
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Work Task
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Participants
Full Name
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Are any Electrical Hazards present?
Electrical Hazard
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Description
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Do these hazards require mitigation action?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Can the voltage be safely isolated?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Are there any bare conductors or missing guards?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Will voltage still be present during work tasks?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Voltages present:
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5 VDC
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24 VDC
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> 24 VDC
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24 VAC
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120 VAC
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240 VAC
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> 240 VAC
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Click if Hydraulic Hazards present?
Hydraulic Hazards
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Description
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Do these hazards require mitigation action?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Is pressure stored in accumulator?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Is pressure stored in hydraulic ram?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Are there any oil leaks or slip hazards?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Could a pump start up unexpectedly?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Are any Mechanical Hazards present?
Mechanical Hazards
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Description
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Do these hazards require mitigation action?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Are there moving parts?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Is the walkway free of debris and oil?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Is there a fall hazard?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Is there a crushing hazard?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
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Could any machines start/ move without warning?
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High risk hazards should be mitigated to reduce the likely hood or severity of the hazard. List actions taken to reduce identified hazards.
Lock-Out Tag-Out
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LOTO needed?
LOTO
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What voltage will be isolated?
- 5 VDC
- 24 VDC
- Greater than 24 VDC
- 24 VAC
- 120 VAC
- 240 VAC
- Greater than 240 VAC
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List isolation points
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Date & Time Locked Out
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Isolation point locked out & verified Cold: print initials
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Isolation verified Cold: print initials
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Perform work
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Authorize LOTO Release: print initials
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Date & Time LOTO Released
