Risk Assessment - Supervisor Assessment

• Operator

• Location Name / Number

• Conducted on

  Date

• Prepared by

• Location
  Address

• Other Personnel on site

Weather Conditions

• Clear / Partly Cloudy

  Yes

  N/A

• Rain

  Yes

  N/A

• Snow

  Yes

  N/A

• Fog

  Yes

  N/A

• Cold (lower than 20 F)

  Yes

  N/A

• If Yes, input approximate temperature

• Heat (higher than 85 F)

  Yes

  N/A

• If Yes, input approximate temperature

• High Wind (greater than 20 mph)

  Yes

  N/A

• If Yes, input approximate wind speed

Driving Surface

• Dry

  Yes

  N/A

• Mud / Deep Ruts

  Yes

  N/A

• Ice / Packed Snow

  Yes

  N/A

• Snow Drifts

  Yes

  N/A

• Standing Water

  Yes

  N/A

• Holes/Pits/Trenches

  Yes

  N/A

Equipment

• Work-Over Rig on location

  Yes

  N/A

• Does the rig or any rig equipment block and or obstruct safe route of travel?

  Yes

  No

• Is there any other equipment being used on location?

  Yes

  N/A

• Does any of the equipment block and or obstruct a safe route of travel?

  Yes

  No

Other Info

• Is there any existing damage to location, equipment, or environment? If yes please explain.

  Yes

  No

  N/A

• Are there any unique features of the location that could create hazards (geography, layout, etc.)? If yes please explain.

  Yes

  No

  N/A

• Any other special instructions (longer hose needed, not able to back up, etc.)? If yes please explain.

  Yes

  No

  N/A

• FOR THIS SECTION ONLY (OTHER INFO) If you answered yes to any question, you must contact Pumper. Has Pumper been contacted?

  Yes

  No

  N/A

• Pumper's First and Last Name

• Date Pumper was contacted

• Time Pumper was contacted

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• Auditor's signature

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