Seismic Site Hazard Assessment

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Type of work being performed on this work site?

• Advance Man

  Yes

  No

  N/A

• Surveying

  Yes

  No

  N/A

• Mulching

  Yes

  No

  N/A

• Drilling

  Yes

  No

  N/A

• Recording

  Yes

  No

  N/A

Location of work being preformed for GWR

• Please add GPS coordinates for Program Staging Location.

• Nearest Town or City to Program Staging Location.

• Please describe direction to the nearest Hospital from the Program Staging location.

Personal Protective Equipment Required by Client/Contractor

• CSA or DOT Approved Helmet

  Yes

  No

  N/A

• CSA Approved Hard Hat

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Foot Protection

  Yes

  No

  N/A

• Hand Protection

  Yes

  No

  N/A

• Personal First Aid Kit

  Yes

  No

  N/A

• Emergency Response Plan

  Yes

  No

  N/A

• Personal H2S Monitor

  Yes

  No

  N/A

• Fire Retardant Coveralls

  Yes

  No

  N/A

Emergency Response Equipment required on this worksite?

• Is there a medic required on program?

  Yes

  No

  N/A

• Is there a requirement for an EMT Vehicle on this Program?

  Yes

  No

  N/A

• Is there a Fire Truck required on the program?

  Yes

  No

  N/A

• Is a helicopter required on the program?

  Yes

  No

  N/A

• Is fire response equipment required in or on all vehicles?

  Yes

  No

  N/A

• Are First Aid kits required in or on all vehicles?

  Yes

  No

  N/A

• Are emergency shut off switches required on Diesel Engines?

  Yes

  No

  N/A

• Is Respiratory Equipment required on site?

  Yes

  No

  N/A

• Are H2S monitors required on site?

  Yes

  No

  N/A

• Is there any other or specialty equipment needed on this program?

  Yes

  No

  N/A

On Site Hazard Information

• H2S

  Yes

  No

  N/A

• SO2

  Yes

  No

  N/A

• Plant or Production Facilities

  Yes

  No

  N/A

• Oil Wells

  Yes

  No

  N/A

• High Pressure Pipelines

  Yes

  No

  N/A

• Low Pressure Pipeline

  Yes

  No

  N/A

• Hazardous Material

  Yes

  No

  N/A

• Buried Facilities Fiber Optic, Power, Telephone, Water......

  Yes

  No

  N/A

• Overhead Powerlines

  Yes

  No

  N/A

• Crown Land

  Yes

  No

  N/A

• Private Property including Acreages

  Yes

  No

  N/A

• Abandon Farm Yards

  Yes

  No

  N/A

• Farm Yards

  Yes

  No

  N/A

• Water Wells

  Yes

  No

  N/A

• Septic Feilds

  Yes

  No

  N/A

• Live Stock

  Yes

  No

  N/A

• Corals

  Yes

  No

  N/A

• Dug Outs

  Yes

  No

  N/A

• Crops

  Yes

  No

  N/A

• Grazing Pasture

  Yes

  No

  N/A

• Humics

  Yes

  No

  N/A

• Badger Holes

  Yes

  No

  N/A

• Barb Wire Fences

  Yes

  No

  N/A

• Wooden Fences

  Yes

  No

  N/A

• Rock Piles

  Yes

  No

  N/A

• Junk Piles

  Yes

  No

  N/A

• Railway

  Yes

  No

  N/A

• Roads

  Yes

  No

  N/A

• Ditches

  Yes

  No

  N/A

• Irrigation Ditches

  Yes

  No

  N/A

• Trees

  Yes

  No

  N/A

• Brush

  Yes

  No

  N/A

• Muskeg

  Yes

  No

  N/A

• Sloughs

  Yes

  No

  N/A

• Creeks

  Yes

  No

  N/A

• Rivers

  Yes

  No

  N/A

• Lakes

  Yes

  No

  N/A

• Cliffs

  Yes

  No

  N/A

• Mountains

  Yes

  No

  N/A

• Hills

  Yes

  No

  N/A

• Please Add any other Hazards associated to this here

  Yes

  No

  N/A

Predatory Hazards

• Hunting Season

  Yes

  No

  N/A

• Trapping

  Yes

  No

  N/A

• Bears

  Yes

  No

  N/A

• Cougars

  Yes

  No

  N/A

• Wolverine

  Yes

  No

  N/A

• Badgers

  Yes

  No

  N/A

• Wolves

  Yes

  No

  N/A

• Coyotes

  Yes

  No

  N/A

• Moose

  Yes

  No

  N/A

• Elk

  Yes

  No

  N/A

• Deer

  Yes

  No

  N/A

• Snakes

  Yes

  No

  N/A

• Please add any other Predatory Hazards here

  Yes

  No

  N/A

Driving Hazards

• Wild Life

  Yes

  No

  N/A

• Weather Conditions

  Yes

  No

  N/A

• Icy Roads

  Yes

  No

  N/A

• Wet Roads

  Yes

  No

  N/A

• Gravel Roads

  Yes

  No

  N/A

• Winter Roads

  Yes

  No

  N/A

• Seasonal Roads

  Yes

  No

  N/A

• Railway Crossings

  Yes

  No

  N/A

• Blind Corners

  Yes

  No

  N/A

• Blind Hills

  Yes

  No

  N/A

• Steep Hills

  Yes

  No

  N/A

• Side Hills

  Yes

  No

  N/A

• Pot Holes

  Yes

  No

  N/A

• Steep Road Shoulders

  Yes

  No

  N/A

• Bridges

  Yes

  No

  N/A

• One Lane Bridge

  Yes

  No

  N/A

• Temporary Creek Cossings

  Yes

  No

  N/A

• Gates

  Yes

  No

  N/A

• Fields

  Yes

  No

  N/A

• Driving in to Sun Rise and or Sun Set

  Yes

  No

  N/A

• Driving at Dusk and or Dawn

  Yes

  No

  N/A

• Unmarked Intersections

  Yes

  No

  N/A

• Oilfield Activity

  Yes

  No

  N/A

• Farming Activity

  Yes

  No

  N/A

• Forestry Activity

  Yes

  No

  N/A

• School buses

  Yes

  No

  N/A

• Please Add any other Hazards found associated to driving here.

  Yes

  No

  N/A

Environmental Hazards

• Wind

  Yes

  No

  N/A

• Wind Chill

  Yes

  No

  N/A

• Snow

  Yes

  No

  N/A

• Ice

  Yes

  No

  N/A

• Rain

  Yes

  No

  N/A

• Sun

  Yes

  No

  N/A

• Extreme Cold

  Yes

  No

  N/A

• Extreme Heat

  Yes

  No

  N/A

• Flooding

  Yes

  No

  N/A

• Tornadoes

  Yes

  No

  N/A

• Avalanche

  Yes

  No

  N/A

• Blizzards

  Yes

  No

  N/A

• Insects

  Yes

  No

  N/A

• Air Born Pathogens

  Yes

  No

  N/A

• Water Born Path

  Yes

  No

  N/A

• Please add any other Hazards that deal with the environment here.

  Yes

  No

  N/A