Title Page
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Site conducted
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Technician
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Date
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Work Order #
1. Stop, Step Back, and Think
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Do I understand what I need to do?
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Do I need a SWMS for any 'High Risk Work'?
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Do I need any permits (e.g. hot work / confined space / dig)?
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Do I have the correct PPE in good condition for the task?
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Do I have my vehicle parked appropriately?
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Am I trained, competent, licensed, and fit to perform this task?
2. Identify the Hazards
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Use the graph below to help determine the risk for the task. If the risk is Moderate or Major, Identify suggested control measures to reduce the risk to minor and obtain supervisor approval before conducting any work. List the control measures taken below.
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Work Cannot proceed if the risk cannot be reduced/mitigated below Moderate or Major level, Unless approved by the appropriate level with signed and written procedure.
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Major Risk Level: Must have HSE and senior Management sign off off approved procedure before performing work.
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Moderate Risk Level: Must have Supervisor or higher approval (HSE or Senior Management) And signed off procedure before performing work.
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Minor Risk Level: Task can proceed as long as all risk has been reduced to safe level.
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Before starting work, a Safe Work Method Statement (SWMS) must be completed if your work involves any high risk work or common hazards where someone's health and safety are at risk. (An SWMS will automatically appear for any hazards identified, additional space is available on the next page for any additional SWMS needed)
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Manual handling (e.g. lifting, awkward positions, impacts, over-exertion)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Gravity (e.g. slips, trips, and falls or being struck by falling object)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Mechanical (e.g. caught in moving parts, struck by plant or flying objects)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Electrical (e.g. Electrocution from faulty tools or working close to live power)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Chemical (e.g. inhaling, swallowing, or touching avid, solvents, or asbestos)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Pressure (e.g. contact with highly pressurized fluid/gas or air)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Noise (e.g. hearing damage, masking of emergency alarms)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Biological (e.g. contracting diseases e.g. hepatitis or legionnaires)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Radiation (e.g. exposure to radiation such as x-rays, sunlight, or ultra-violet)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Psychological (e.g. stress, violence, fatigue, depression)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Heat and Cold (e.g. Working with hot.cold objects or exposure to environment)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
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Biological (e.g. contracting diseases e.g. hepatitis or legionnaires)
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What are the hazards and risks?
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Risk Rating
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What are the hazards and risks to control?
Untitled Page
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3. Assess the level of risk:
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Risks Worked Out?
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4. Control the hazards
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SWMS completed? (for each hazard identified on last page)
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Use this space for any additional SWMS
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5. Proceed safely
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Safe to Proceed?
Additional Permits Required
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Confined Space
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Line Breaking
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Other
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LOTO Required?
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Check the following if performed
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Lock
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Tag
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Try
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Hot Work
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Exposure to Live Electrical
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Fill out Routine Electrical Task Permit
Control Methods and Approval
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Use the graph below to help determine the risk for the task. If the risk is Moderate or Major, Identify suggested control measures to reduce the risk to minor and obtain supervisor approval before conducting any work. List the control measures taken below.
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Select level of risk chosen
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Identify suggested control methods:
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Obtain Supervisor Approval
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I have reviewed the following control measure with the employee and agree that these measures minimize the risk of this task (to be signed by supervisor)
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Identify suggested control measures:
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Obtain Senior Management Approval
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I have reviewed this control measure with the employee and agree that these measures minimize the risk of this task (to be signed by supervisor)
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Obtain HSE Approval
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I have reviewed this control measure with the employee and agree that these measures minimize the risk of this task (to be signed by HSE)
Return to Operations Sign-Off
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Complete when returning equipment to production
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1) Neat and orderly: All tools, rags, cleaners, barricades, etc. have been removed from the work zone?
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2) All guards are reattached, in good working order and properly secured with correct hardware?
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3) All Electrical Components, wires, boxes, and switches are functioning and in safe condition?
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4) Equipment was tried for proper operation?
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Settings/adjustments are back to their original position and/or I understand what settings have changed?
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Signature of employee accepting equipment:
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Comments:
