TAKE 5 CNPH

• Location
  Address

• Select date

  Date

• Completed by

• Task being executed

1 - THINK THROUGH THE TASK

• Do you understand the task scope?

  Off

  On

• Does a procedure exist?

  Off

  On

• Do you understand the steps required to do the task?

  Off

  On

• Are tools and equipment in good order?

  Off

  On

• Do you have the correct PPE?

  Off

  On

• Have you got a clear plan in mind?

  Off

  On

2 - SPOT THE HAZARDS

• Will I be operating equipment with the guards removed?

  NO

  YES

  N/A

• Am I or other at risk from the operation of vehicles or mobile equipment?

  NO

  YES

  N/A

• Does the task involve hazardous materials?

  NO

  YES

  N/A

• Will I be performing a task without a specific isolation procedure?

  NO

  YES

  N/A

• Will I be impacted by others in the vicinity?

  NO

  YES

  N/A

• Will I be working at heights?

  NO

  YES

  N/A

• Other environmental and/or Health & Safety hazards? (List them below)

  NO

  YES

  N/A

LIST ADDITIONAL HAZARDS

• HAZARD

• CONTROLS

• Risk Score

  Select Not Applicable Low (1) Low (2) Low (3) Low (4) Low (5) Moderate (6) Moderate (7) Moderate (8) Moderate (9) High (10) High (11)

  • Not Applicable
  • Low (1)
  • Low (2)
  • Low (3)
  • Low (4)
  • Low (5)
  • Moderate (6)
  • Moderate (7)
  • Moderate (8)
  • Moderate (9)
  • High (10)
  • High (11)

• HAZARD

• CONTROLS

• Risk Score

  Select Not Applicable Low (1) Low (2) Low (3) Low (4) Low (5) Moderate (6) Moderate (7) Moderate (8) Moderate (9) High (10) High (11)

  • Not Applicable
  • Low (1)
  • Low (2)
  • Low (3)
  • Low (4)
  • Low (5)
  • Moderate (6)
  • Moderate (7)
  • Moderate (8)
  • Moderate (9)
  • High (10)
  • High (11)

3 - ASSESS THE RISKS

• Is the risk level equal to or higher than H11? <br>If YES complete a JHA.

  NO

  YES

4 - MAKE THE CHANGES

• Implement Controls and Review Take 5 if changes in the task occur.

5 - DO THE TASK SAFELY

PROCEED

• Operator Signature

  Sign