Information
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Department
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Area
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Task Evaluated:
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Conducted on
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Prepared by
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Personnel
MOBILITY
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
MOBILITY - Can I be harmed by a slip, trip, or fall from: -
Moving on my normal work surface?<br>
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Moving up or down stairs?<br>
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An improperly placed machine, equipment, tool, or material?<br>
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Multi tasking where I could be distracted?<br>
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Slippery materials on the floor or ground such as ice, snow, oil?<br>
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Rushing to meet production or work demands?<br>
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Falling from or being thrown from a vehicle?<br>
ENERGY
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
ENERGY - Can I be harmed by exposure to uncontrolled energy sources including: -
Hazardous chemical substances?<br>
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Electrical sources?<br>
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Hot or cold substances?<br>
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Radioactive or ionizing radiation sources?<br>
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Pressurized vessels, equipment, lines, or hoses?<br>
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Non-ionizing radiation?<br>
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Stored energy from equipment, tools, vehicles, or materials?<br>
CONTACT
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
CONTACT - Can I be harmed by contacting, colliding, striking, or getting caught on: -
Sharp objects?<br>
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Moving, sliding, spinning, or rolling objects?<br>
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Flying or falling objects or substances?<br>
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Moving vehicles, machines, equipment, tools, or materials?<br>
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Chemical substances?<br>
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Hot or cold surfaces or materials?<br>
CRUSH
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
CRUSH - Can I be harmed by being crushed by: -
A moving vehicle or machine and stationary object?<br>
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Trying to clear a jammed machine?<br>
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A moving machine part?<br>
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A moving or rolling object, tool, product, equipment, or material?<br>
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A falling object, tool, product, equipment, or material?<br>
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A collapsing structure?<br>
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Soil or rock from a collapsing excavation?<br>
GRAVITY
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
GRAVITY - Can I be harmed by falling from heights while working, walking, or climbing: -
On an elevated work location?<br>
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To or from an elevated work location?<br>
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Near holes, crevices, shafts, pits, or excavations?<br>
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Near wall openings such as docks?<br>
ERGONOMIC
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
ERGONOMIC - Can I experience excessive pains, strains, or sprains from: -
Conducting repetitive tasks?<br>
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Lifting and/or carrying heavy loads?<br>
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Pushing, pulling, twisting, reaching, or forceful motions?<br>
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Awkward or stationary postures?<br>
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Prolonged contact with a tool, machine, equipment, or material?<br>
HEALTH
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
HEALTH - Can I be harmed by: -
Breathing any unsafe substance?<br>
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Swallowing any unsafe substance?<br>
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Being injected with any unsafe substance?<br>
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Absorbing any unsafe substance through my skin?<br>
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Working around any biological agents, insects, or plants?<br>
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Working around excessive noise?<br>
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Working around prolonged vibration?<br>
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Working in dim lighting or bright glare?<br>
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Working in extremely hot or cold conditions?<br>
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Working in an oxygen-deficient atmosphere?<br>
UNIQUE
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
UNIQUE - Can I be harmed by: -
Rushing or taking a shortcut to meet production demands?<br>
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Work situations that cause excessive fatigue?<br>
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Inadequate training, knowledge, or skills to safely do this job?<br>
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Risks from inadequate resources, tools, or equipment?<br>
OTHER
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LOOK …for hazards and risks associated with a task
THINK …of ways to reduce or eliminate them
ACT …do something to protect yourself and others
Check NO if the hazard is not present.
Check NO if controls sufficiently reduce hazard/risk to an acceptable level.
Check YES if a hazard is present, and controls are absent or not sufficient.
OTHER - Can I be harmed by: -
Any other hazards I identified, not covered above?<br>
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For all YES answers: Follow your facility's process to address identified hazards (EHS Alerts, Find and Fix).
