Title Page

  • Task

  • Location
  • Conducted by

  • Conducted on

Stop and Think Through the Task

  • Do I clearly understand what is required?

  • Am I trained to do the work and familiar with the equipment/task?

  • Are the tools and equipment in a safe condition?

  • Do I have approved documentation for the task?

  • Have I informed others who may be affected by my work?

  • Do I have the correct PPE/RPE for the task (identified in the risk assessment/method statement)?

Identify and Assess the Hazards

  • Provide corrective actions for hazards identified by clicking on 'Action' on the items below. Describe the action to take, assign a member, set priority level and due date.

  • Hazard
  • Hazard type

  • Please specify hazard type

  • Take or attach photo evidence of hazard identified

  • Describe the hazard

  • Refer to image below for risk level

  • Priority for action

  • Refer to image below for likelihood

  • Likelihood

  • Control measure

Control and Monitor

  • Are all hazards identified controlled or removed?


  • Name & Signature of Assigned Employee

  • Name & Signature of Supervisor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.