Sample - Field Level Hazard Assessment

• Audit Title

• Customer

• Conducted on

  Date

• Person Conducting Assessment

• Location of Task
  Address

• Description of Activity

• Answer the following questions by selecting YES or NO
  
  You can add Media, Notes and Actions as necessary by clicking on the paper clip icon on the upper right corner of the question.
  - Upload images through the Add Media option.
  - Indicate notes through the Add Note option.
  - Assign to another user with a priority level and due date, and they will be notified in real-time via email, text (SMS) or push notification through the Add Action option.

Evaluating Your Work Area and Tasks

• Have you walked the area?

  YES

  NO

• Do you have PPE available?

  YES

  NO

• Are you working around live systems?

  YES

  NO

• Does this task require special training?

  YES

  NO

• Are underground utilities located?

  YES

  NO

• Tools and equipment inspected?

  YES

  NO

• Are work permits required?

  YES

  NO

• Tools and material available?

  YES

  NO

• Are evacuation routes established?

  YES

  NO

• Are there previously unidentified safety issues?

  YES

  NO

• Are fire extinguishers and First Aid available?

  YES

  NO

• Is a fall protection plan required?

  YES

  NO

• Have all workers attended the Site Specific Safety Orientation?

  YES

  NO

• Have we co-ordinated activities with other subcontractors?

  YES

  NO

• New/Young Worker on Crew?

  YES

  NO

• New Tools or Equipment?

  YES

  NO

• Adequate Time and Crew Provided to Complete Tasks?

  YES

  NO

• Adequate Tools and Equipment?

  YES

  NO

Potential Hazard Checklist

• Identify the Potential Hazard Checklist by selecting items on the dropdown list:

  Select

• What other hazard is present?

PPE Required

• Check the PPE Requirement if available.

• Hard Hat

• Hi-Visibility Vest

• Safety Boots

• Eye Protection

• Gloves

• Respirators

• Face Shield

• Ear Protection

RISK ASSESSMENT

• RISK ASSESSMENT MATRIX

  

• Risk Assessment:
  1-5 is considered Low Risk: work may commence
  6-10 is considered Moderate Risk: Action needs to be taken to eliminate or minimize risk prior to work commencing
  11-15 is considered High Risk: Immediate action must be taken to eliminate or minimize risk down to a Low to Moderate Risk with controls in place prior to work commencing. If this is not possible then job task cannot commence
  16-25 is considered Extreme Risk: Job shutdown, urgent action must be taken to eliminate or minimize risk down to a Low or Moderate Risk with controls in place prior to work commencing. If this is not possible then the job task cannot commence
  
  Click the ADD button to add a TASK
  Step 1 - Identify the Task
  Step 2 - Identify the Hazards
  Step 3 - Conduct Risk Assessment by using the Matrix above
  Step 4 - Actions to Eliminate / Control Hazard

• Add TASK and identify the HAZARDS

Task

• Step 1 Identify Task

• Step 2 Identify Hazards

• Step 3 Conduct Risk Assessment

• Low Risk: work may commence

  

• Moderate Risk: Action needs to be taken to eliminate or minimize risk prior to work commencing

  

• High Risk: Immediate action must be taken to eliminate or minimize risk down to a Low to Moderate Risk with controls in place prior to work commencing. If this is not possible then job task cannot commence

  

• Extreme Risk: Job shutdown, urgent action must be taken to eliminate or minimize risk down to a Low or Moderate Risk with controls in place prior to work commencing. If this is not possible then the job task cannot commence

  

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Click ADD to SIGN

• Worker Full Name and Signature

  Sign