Safety Hazard Review Checklist

• Task

• Work Order#

• Client / Site

• Conducted on

  Date

• Prepared By:

• Location
  Address

Potential Hazards

• Potential Hazards

  Select Airborne Contaminants Animals Asbestos Biological Hazards Compressed Gasses Confined Space Electrical Ergonomics Excavation, Trenching, Shoring Fall Hazard Fire Hazard Hazardous Chemicals Hazardous Energy Heat Stress Laboratory Lead Powered Materials Handling Mold Noise Overhead Radiation Scaffolding Heavy Equipment Welding/Torch Cutting/Soldering Other

  • Airborne Contaminants
  • Animals
  • Asbestos
  • Biological Hazards
  • Compressed Gasses
  • Confined Space
  • Electrical
  • Ergonomics
  • Excavation, Trenching, Shoring
  • Fall Hazard
  • Fire Hazard
  • Hazardous Chemicals
  • Hazardous Energy
  • Heat Stress
  • Laboratory
  • Lead
  • Powered Materials Handling
  • Mold
  • Noise
  • Overhead
  • Radiation
  • Scaffolding
  • Heavy Equipment
  • Welding/Torch
  • Cutting/Soldering
  • Other

• Airborne Contaminants

  Select Animal Dander Gas Mist Metal Dust or Fume Wood Dust Silica General Room Dust(paper, soil, clothing fibers) Vapor

  • Animal Dander
  • Gas
  • Mist
  • Metal Dust or Fume
  • Wood Dust
  • Silica
  • General Room Dust(paper, soil, clothing fibers)
  • Vapor

• Method of mitigating exposure to silica:

  Select Water use while drilling/cutting HEPA Vacuum N95 NIOSH Respirator Other

  • Water use while drilling/cutting
  • HEPA Vacuum
  • N95 NIOSH Respirator
  • Other

• Electrical

  Select Extension Cords (GFCI Required) Generators Power Lines (overhead/underground) Outdoors and/or Moist Environments (GFCI protection required) Exposed Energized Electrical Equipment Arc Flash Hazard

  • Extension Cords (GFCI Required)
  • Generators
  • Power Lines (overhead/underground)
  • Outdoors and/or Moist Environments (GFCI protection required)
  • Exposed Energized Electrical Equipment
  • Arc Flash Hazard

• Boundary Approach

  

• List PPE being used in the "PPE" section

• Lockout/Tagout Trained?

  Yes

  No

  N/A

• Ergonomics

  Select Lifting Repetitive Motion High Force Awkward Posture

  • Lifting
  • Repetitive Motion
  • High Force
  • Awkward Posture

• Fire Hazards

  Select Hot Work Flammable Materials Other

  • Hot Work
  • Flammable Materials
  • Other

• Other

• Hazardous Energy

  Select Heat Hydraulic Stored Energy Pressure Other

  • Heat
  • Hydraulic
  • Stored Energy
  • Pressure
  • Other

• Other

• Laboratory

  Select Pre-work Decontamination Required FS Tool/ Equipment Decontamination Required Other

  • Pre-work Decontamination Required
  • FS Tool/ Equipment Decontamination Required
  • Other

• Other

• Scaffolding

  Select < 10' High > 10' High No Guardrails Other

  • < 10' High
  • > 10' High
  • No Guardrails
  • Other

• Other

• Other

SafeGuards & Control Measures

• SafeGuards

  Select Administrative Controls Site Control Engineering Controls Emergency(s) Other

  • Administrative Controls
  • Site Control
  • Engineering Controls
  • Emergency(s)
  • Other

• Administrative Controls

  Select Lockout/Tagout Hot Work Permit Fall Protection Work Plan Blind Penetration Permit Lab/Department Specific Procedures Lead Work Plan Energized Electrical Permit and Work Plan Notice of Lab Equipment Decontamination Employee Rotation

  • Lockout/Tagout
  • Hot Work Permit
  • Fall Protection Work Plan
  • Blind Penetration Permit
  • Lab/Department Specific Procedures
  • Lead Work Plan
  • Energized Electrical Permit and Work Plan
  • Notice of Lab Equipment Decontamination
  • Employee Rotation

• Site Control

  Select Secure Access/Check-in Barricades Signs Traffic Control Other

  • Secure Access/Check-in
  • Barricades
  • Signs
  • Traffic Control
  • Other

• Other

• Engineering Controls

  Select Additional Ventilation Noise Controls Temporary Lighting Electrical Disconnect Enclosure Electrical Shutdown Building System Shutdown

  • Additional Ventilation
  • Noise Controls
  • Temporary Lighting
  • Electrical Disconnect
  • Enclosure
  • Electrical Shutdown
  • Building System Shutdown

• Emergency(s)

  Select Means of Emergency Communication Established First Aid Kit Present Fire Extinguisher Available Emergency Exit(s) Location Known

  • Means of Emergency Communication Established
  • First Aid Kit Present
  • Fire Extinguisher Available
  • Emergency Exit(s) Location Known

• Other

Personal Protective Equipment (PPE)

• PPE Required

  Select Body Eye Face Fall Protection Foot Hand Head Hearing Protection Respiratory Other

  • Body
  • Eye
  • Face
  • Fall Protection
  • Foot
  • Hand
  • Head
  • Hearing Protection
  • Respiratory
  • Other

• Body

  Select Coveralls Tyvek Arc Rated Other

  • Coveralls
  • Tyvek
  • Arc Rated
  • Other

• Other

• Eye

  Select Impact Goggle/Glasses Dust Goggles Chemical Goggles Other

  • Impact Goggle/Glasses
  • Dust Goggles
  • Chemical Goggles
  • Other

• Other

• Face

  Select Impact Face Shield UV/Heat Face Shield (hood) Chemical Splash Face Shield Other

  • Impact Face Shield
  • UV/Heat Face Shield (hood)
  • Chemical Splash Face Shield
  • Other

• Other

• Fall Protection

  Select Full Body Harness Safety Net System Guardrail Systems Other

  • Full Body Harness
  • Safety Net System
  • Guardrail Systems
  • Other

• Other

• Foot

  Select Steel Toe Shoe Covers Steel Shank Metatarsal Covers

  • Steel Toe
  • Shoe Covers
  • Steel Shank
  • Metatarsal Covers

• Hand

  Select Cotton Gloves Puncture Resistant Gloves Leather Gloves Electrically Rated Gloves Chemically Resistant Gloves

  • Cotton Gloves
  • Puncture Resistant Gloves
  • Leather Gloves
  • Electrically Rated Gloves
  • Chemically Resistant Gloves

• Head

  Select Hard Hat Arc Rated Hood Other

  • Hard Hat
  • Arc Rated Hood
  • Other

• Respiratory

  Select Dust Mask PAPR Full Face, Negative Pressure Half Face, Negative Pressure Other

  • Dust Mask
  • PAPR
  • Full Face, Negative Pressure
  • Half Face, Negative Pressure
  • Other

• Other

• Other

Permits

• Permits Being Used

  Yes

  No

  N/A

• Permits

  Select Blind Penetration Confined Space Energized Electrical Work Dig Hot Work Other

  • Blind Penetration
  • Confined Space
  • Energized Electrical Work
  • Dig
  • Hot Work
  • Other

Blind Penetration

• Drilling into:

  Select Drywall Concrete/Block Other

  • Drywall
  • Concrete/Block
  • Other

• Silica Dust Hazards in Construction Training Completed?

  Yes

  No

  N/A

• Method for mitigating silica dust exposure is listed in the Airborne Contaminants section under Potential Hazards

Energized Electrical Work

• Approach Boundaries for energized work along with proper PPE is listed In the above categories under "Potential Hazards" and "PPE"

• Approval Needed for Energized Electrical Work?

  Yes

  No

  N/A

• Approval Granted By:

  Sign

Confined Space

• Method of rescue/retrieval:

  Select Retrieval Line Chest or Full Body Harness Wristlets Lifting Device or Anchor Other

  • Retrieval Line
  • Chest or Full Body Harness
  • Wristlets
  • Lifting Device or Anchor
  • Other

• Other

• Respirator Required?

  Yes

  No

  N/A

• Atmospheric Testing Completed?

  Yes

  No

  N/A

• Oxygen Deficient Atmosphere --> Less than 19.5% Oxygen by volume
  
  Oxygen Enriched Atmosphere --> More than 23.5% Oxygen by volume
  
  Oxygen levels should be between the levels listed above for the safest environment.

Dig Permit

• Safety Vest Available

  Yes

  No

  N/A

• Hard Hat(if applicable)

  Yes

  No

  N/A

Hot Work

• Means of Extinguishing Fire Available

  Yes

  No

  N/A

• Hot Work in Confined Space

  Yes

  No

  N/A

• Respirator Required?

  Yes

  No

  N/A

• Proper ventilation in place

  Yes

  No

  N/A

• Combustible Materials located at least 35 feet away from hot work

  Yes

  No

  N/A

• PPE being used for Hot Work listed above in "PPE"

• Other

Training

• Training Applicable

  Select Arial Personnel Lift/Powered Platform Lift Asbestos Awareness Asbestos 8-hour for specific material Back Protection BloodBorne Pathogen Confined Space Awareness Confined Space Entry Fall Protection & Ladder Safety First Aid Forklift Safety Hearing Conservation Hoist/Lift Training (non-crane) Hoist Lift & Crane Training Lead Awareness Lead Worker Lockout Safety Respiratory Protection Scaffold Safety Other

  • Arial Personnel Lift/Powered Platform Lift
  • Asbestos Awareness
  • Asbestos 8-hour for specific material
  • Back Protection
  • BloodBorne Pathogen
  • Confined Space Awareness
  • Confined Space Entry
  • Fall Protection & Ladder Safety
  • First Aid
  • Forklift Safety
  • Hearing Conservation
  • Hoist/Lift Training (non-crane)
  • Hoist Lift & Crane Training
  • Lead Awareness
  • Lead Worker
  • Lockout Safety
  • Respiratory Protection
  • Scaffold Safety
  • Other

• Other

Jefferson Lab Training

• Training being used:

  Select Activity Hazard Analysis Preparation (SAF 133) Aerial Platform/Manlift (SAF 302) Forklift Operator (SAF 502) Fire Safety (SAF 108) General Access RWP (SAF 108kd) General Employee Radiation Training (SAF 800) Hall Work Governance (SAF 116kd) Hall A Worker Awareness Training (SAF 110) Hall B Worker Awarness Training (SAF 111) Hall C Worker Awareness Training (SAF 112) Hall D Worker Awareness Training (SAF 113) Lock, Tag, and Try (SAF 104) NFPA 70E - Basic Electrical Training (SAF 603N) Oxygen Deficiency Hazards - ODH (SAF 138) Radworker 1 (SAF 801) Silica Dust Hazards in Construction (SAF 138) Spill Prevention Control and Counter Measure Plan (SAF 123) Other

  • Activity Hazard Analysis Preparation (SAF 133)
  • Aerial Platform/Manlift (SAF 302)
  • Forklift Operator (SAF 502)
  • Fire Safety (SAF 108)
  • General Access RWP (SAF 108kd)
  • General Employee Radiation Training (SAF 800)
  • Hall Work Governance (SAF 116kd)
  • Hall A Worker Awareness Training (SAF 110)
  • Hall B Worker Awarness Training (SAF 111)
  • Hall C Worker Awareness Training (SAF 112)
  • Hall D Worker Awareness Training (SAF 113)
  • Lock, Tag, and Try (SAF 104)
  • NFPA 70E - Basic Electrical Training (SAF 603N)
  • Oxygen Deficiency Hazards - ODH (SAF 138)
  • Radworker 1 (SAF 801)
  • Silica Dust Hazards in Construction (SAF 138)
  • Spill Prevention Control and Counter Measure Plan (SAF 123)
  • Other

• Other

Waste Disposal

• Hazardous Waste Generated?

  Yes

  No

  N/A

• Waste Assessment Needed?

  Yes

  No

  N/A

Signatures

• Form Completed By:

  Sign

• Personnel

  Sign

• Personnel

  Sign

• Personnel

  Sign

• Approval Required?

  Yes

  No

  N/A

• Form Approved By:

  Sign