Title Page

  • Site

  • Conducted on

  • Prepared by

EVERY TASK CAN BE COMPLETED SAFELY AND WITHOUT ENVIRONMENTAL INCIDENT All accidents, injuries, fires, and near misses, no matter how small, shall be reported immediately

  • Job Description

Work Area Assessment

  • Do I know the wind direction?

  • Do I know where to find a safety shower, fire extinguisher, and fire monitor?

  • Is a safe means of access and exit provided to my work area?

  • Do I know how and have the means available to report an emergency?

  • Do I know what to do in the event of an emergency? (Understand alarm system, evacuation routes, assembly areas, etc.)

  • Have I identified potential safety and environmental hazards associated with this task and taken all reasonable steps to remove them?


  • Am I in the right frame of mind and focused on the task at hand? (Motivated, ready to work safely, etc.)

  • Do I know how to do this task safely and without environmental incident?

  • Do I need a second opinion or help performing this task? (It's OK and expected that you get help when needed)


  • Do I have the correct tool(s) and equipment to perform the task safely and without environmental incident?

  • Have I inspected the tools and verified that they are safe to use?

Secondary Effects

  • Have I informed others in the area that might be affected by what I am doing?

  • Am I aware of "the line of fire"?

  • Is my work properly controlled so that my coworkers and I will not be adversely affected by potentially hazardous conditions resulting from this task?

  • Does the task at hand affect a downstream process and have those effects been communicated to those process owners?

Reminder / Responsibility

  • Am I aware of the written as well as the unwritten procedure associated with this task?

  • Have I identified potential sources of leaks or spills associated with task and made plans to address these possible sources? (Secondary containment)

  • Does this task require a safe work permit?

  • Did the process overview on the safe work permit adequately cover all pertinent information required to safely complete the task at hand?

  • Does this task require an MOC?

  • I will clean up when this task is complete. (Leave it better than I found it)

  • I will dispose of waste properly. (And, if I don't know, I will ask)

  • I know I can complete this task safely and without environmental incident. (If not, I will ask for help and repeat this checklist before starting work)

Personal Protection

  • Do I know the proper PPE for this task and am I wearing it? (Follow safe work practices and MSDS)

  • Do I need to familiarize myself with an MSDS for this job?

  • Suggestions for improved safety and environmental performance:

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.