Revamp Industries - Field Level Hazard Assessment

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

POTENTIAL HAZARDS

• Environmental Hazards

  Select 1. Work area clean 2. Material storage identified 3. Dust/mist/fumes 4. Noise in area 5. Extreme temperatures 6. Spill potential 7. Waste properly managed 8. Excavation permit required 9. Other workers in area 10. Weather conditions 11. MSDS reviewed

  • 1. Work area clean
  • 2. Material storage identified
  • 3. Dust/mist/fumes
  • 4. Noise in area
  • 5. Extreme temperatures
  • 6. Spill potential
  • 7. Waste properly managed
  • 8. Excavation permit required
  • 9. Other workers in area
  • 10. Weather conditions
  • 11. MSDS reviewed

• Ergonomic Hazards

  Select 12. Awkward body position 13. Over extension 14. Prolonged twisting/repetitive/ bending motion 15. Working in tight area 16. Lift too heavy/awkward to lift 17. Hands not in line of sight 18. Working above your head

  • 12. Awkward body position
  • 13. Over extension
  • 14. Prolonged twisting/repetitive/ bending motion
  • 15. Working in tight area
  • 16. Lift too heavy/awkward to lift
  • 17. Hands not in line of sight
  • 18. Working above your head

• Access/Egress Hazards

  Select 19. Aerial lift/man basket (inspected & tagged) 20. Scaffold (inspected & tagged) 21. Ladders (tied off) 22. Slips/trips 23. Hoisting (tools, equipment) 24. Evacuation (alarms, routes, ph.#) 25. Confined/restricted space entry permit required

  • 19. Aerial lift/man basket (inspected & tagged)
  • 20. Scaffold (inspected & tagged)
  • 21. Ladders (tied off)
  • 22. Slips/trips
  • 23. Hoisting (tools, equipment)
  • 24. Evacuation (alarms, routes, ph.#)
  • 25. Confined/restricted space entry permit required

• Overhead Hazards

  Select 26. Barricades & signs in place 27. Hole coverings identified 28. Harness/lanyards inspected 29. 100% tie-off with harness and anchor points identified 30. Falling objects 32. Hoisting or moving loads overhead

  • 26. Barricades & signs in place
  • 27. Hole coverings identified
  • 28. Harness/lanyards inspected
  • 29. 100% tie-off with harness and anchor points identified
  • 30. Falling objects
  • 32. Hoisting or moving loads overhead

• Rigging & Hoisting Hazards

  Select 33. Lift study required 34. Proper tools used 35. Tools/sling inspected 36. Equipment inspected 37. Others working overhead/below 38. Critical lift permit

  • 33. Lift study required
  • 34. Proper tools used
  • 35. Tools/sling inspected
  • 36. Equipment inspected
  • 37. Others working overhead/below
  • 38. Critical lift permit

• Electrical Hazards

  Select Hard Hat Safety Glasses FR Coveralls CSA Work Boots Long Sleeves Face Shield Gloves

  • Hard Hat
  • Safety Glasses
  • FR Coveralls
  • CSA Work Boots
  • Long Sleeves
  • Face Shield
  • Gloves

• Personal Limitations/Hazards

  Select 45. Procedure not available for task 46. Confusing instruction 47. No training for task or tools to be used 48. First time performing the task

  • 45. Procedure not available for task
  • 46. Confusing instruction
  • 47. No training for task or tools to be used
  • 48. First time performing the task

• PPE Required

  Select Hard Hat Safety Glasses FR Coveralls CSA Work Boots Long Sleeves Face Shield Gloves

  • Hard Hat
  • Safety Glasses
  • FR Coveralls
  • CSA Work Boots
  • Long Sleeves
  • Face Shield
  • Gloves

GENERAL INFORMATION

• Work to be done:

• Muster point:

• Permit job #:

• PPE inspected:

JOB TASKS

• Select off the hazards that apply to this job. , indicate the priority ranking and identify the plans to eliminate or control on the other side of this template.

• Click "Add Task"

Task

• Specify Task

• HAZARDS

• Severity

  1. Imminent Danger

  2. Serious

  3. Minor

  4. Not Applicable – N/A

• Probability<br>

  A. Probable

  B. Reasonably Probable

  C. Remote

  D. Extremely Remote

• Plans to eliminate/control

• Has a pre-use inspection of tools/equipment been completed?

  Yes

  No

• Warning ribbon needed?

  Yes

  No

• Is the worker working alone?

  Yes

  No

• Explain

JOB COMPLETION

• Are all Permit(s) closed out?

  Yes

  No

• Was the area cleaned up at end of job/shift?

  Yes

  No

• Are there Hazards remaining?

  Yes

  No

• Explain

• Were there any incidents/injuries

  Yes

  No

• Explain

WORKER'S SIGN-OFF

• Please print and sign below (All members of the crew) prior to commencing work, and initial when task is completed or at the end of the shift.

• Click "Add Worker's Signature"

Worker's Signature

• Worker's Name & Signature

  Sign

FOREPERSON SIGN-OFF

• (Sign upon reviewing completed card)

• Name & Signature

  Sign

CLIENT'S REPRESENTATIVE SIGN-OFF

• Review

• Name & Signature

  Sign