SL - FLHA Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Company or Contractor Name

• Lead or Supervisor Name

• Lead or Supervisor Phone #

• Describe the task(s) being performed

Hazards

• Physical

  Select Housekeeping Material Storage & Handling Slip/Trip/Fall Potential Blocked Exits & Walkways Confined / Restricted Space Improper Ventilation Powerlines Overhead / Underground Ground / Surface Condition Open Excavation Lighting Weather Hot Work Vehicle / Pedestrian Traffic Working at Heights Scaffolding Falling Objects Loads Moving or Being Hoisted Ladder Use Critical Lift Others Working Below / Overhead Incorrect Tools / Equipment Working on / Near Energized Equipment Defective Tools/Equipment Noise Vibration Other

  • Housekeeping
  • Material Storage & Handling
  • Slip/Trip/Fall Potential
  • Blocked Exits & Walkways
  • Confined / Restricted Space
  • Improper Ventilation
  • Powerlines Overhead / Underground
  • Ground / Surface Condition
  • Open Excavation
  • Lighting
  • Weather
  • Hot Work
  • Vehicle / Pedestrian Traffic
  • Working at Heights
  • Scaffolding
  • Falling Objects
  • Loads Moving or Being Hoisted
  • Ladder Use
  • Critical Lift
  • Others Working Below / Overhead
  • Incorrect Tools / Equipment
  • Working on / Near Energized Equipment
  • Defective Tools/Equipment
  • Noise
  • Vibration
  • Other

• Ergonomic

  Select Awkward Body Positioning Overextension Repetitive Motion Twisting / Reaching / Bending Cramped / Tight Work Area Forceful Pushing / Pulling Awkward Grip / Load Carried Awkward Grip / Load Carried Other

  • Awkward Body Positioning
  • Overextension
  • Repetitive Motion
  • Twisting / Reaching / Bending
  • Cramped / Tight Work Area
  • Forceful Pushing / Pulling
  • Awkward Grip / Load Carried
  • Awkward Grip / Load Carried
  • Other

• Chemical

  Select Freeze Burn Chemical Handling / Storage Spill Potential Dust / Fumes / Vapors / Gases Fire/Explosion/Reactive Properties Acid / Corrosive Material Aerosols Other

  • Freeze Burn
  • Chemical Handling / Storage
  • Spill Potential
  • Dust / Fumes / Vapors / Gases
  • Fire/Explosion/Reactive Properties
  • Acid / Corrosive Material
  • Aerosols
  • Other

• Biological

  Select Waste Disposal Blood / Bodily Fluid Virus / Bacteria Insect Bite Lack of Hygiene / Sanitation Other

  • Waste Disposal
  • Blood / Bodily Fluid
  • Virus / Bacteria
  • Insect Bite
  • Lack of Hygiene / Sanitation
  • Other

• Psychosocial

  Select Personal Limitations / Illness, Age, Mental Stability Harassment / Violence Stress / Fatigue Working Alone Worker(s) NOT Competent

  • Personal Limitations / Illness, Age, Mental Stability
  • Harassment / Violence
  • Stress / Fatigue
  • Working Alone
  • Worker(s) NOT Competent

• Are Workers Fit for Duty

  Yes

  No

  N/A

• If NOT Fit for Duty – Report to Supervisor

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• List of PPE Required

• PPE Inspected

  Yes

  No

  N/A

• Location of First Aid Supplies:

• Emergency Muster Location(s):

• If Working Alone, Explain Check-In Procedure:

Identify the Hazards and Outline Plans to Eliminate and/or Control Each Hazard

• Tap + to add

• Hazard

• Controls

• Did you Properly Lock Out / Tag Out ANY Defective Equipment?

  Yes

  No

  N/A

• Did you Notify Nearby Workers of ANY Hazards that may Affect Them?

  Yes

  No

  N/A

Worker's Sign off

• Tap + to add

• Worker's Name

• NOTE: If leaving and coming back to a task, workers must record the time and initial, acknowledging that no new hazards are present.

• Sent to Supervisor and Worksite Representative for Approval

  Yes

  No

  N/A

ALL AFFECTED WORKSITE PARTIES MUST SIGN OFF BEFORE WORK CAN BEGIN