Take 5 Risk Assessment Checklist

• Conducted on

  Date

• Prepared by

• Location
  Address

1. STOP & Think

• Task description

• Take photo of work environment

  Media

• Do I clearly understand what is required? Clear instructions?

  Yes

  No

  N/A

• Am I trained to do the work?

  Yes

  No

  N/A

• Am I familiar with the equipment/machinery/task?

  Yes

  No

  N/A

• Are the tools and equipment in a safe condition?

  Yes

  No

  N/A

• Am I safe from other activities/tasks in the area?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Do I have the correct PPE for the Task?

  Yes

  No

  N/A

2. Identify Hazards and Risks

• Are there stored energy risks?

  No

  Yes

• Electrical

  No

  Yes

• Hydraulic

  No

  Yes

• Pnuematic

  No

  Yes

• Chemical

  No

  Yes

• Thermal (Natural Gas)

  No

  Yes

• Are ALL sources of energy isolated and locked out?

  No

  Yes

• If Hazardous Substances are present - ensure Hazardous Substances Permit is completed, has this been done?

  Yes

  No

  N/A

• Is there a risk of injury, If yes what type

  No

  Yes

• Being hit by moving object

  No

  Yes

• Fall, slip or trip

  No

  Yes

• Hitting objects with part of the body

  No

  Yes

• Strained muscle

  No

  Yes

• Contact with heat or cold

  No

  Yes

• Crushing/caught between objects

  No

  Yes

• Cuts/abrasion

  No

  Yes

• Chemical exposure

  No

  Yes

• List controls for any identified risks from above:

• Any other hazards associated with the task?

  No

  Yes

• Description of hazards

• Take photo of hazards

  Media

3. Assess the Level of Risk

• Risk Score

  Low

  Medium

  High

  Extreme

• Notify Manager AND Add additional controls, list them here:

• STOP Work and Reassess - Notify Manager

• Have all potential risks been discussed and understood by all involved in the task?

  No

  Yes

4. Hazards & Risk Controls

• State the controls for the hazards/risks listed above:

• Have all hazard controls been implemented?

  No

  Yes

5. Proceed Safely

• Other observations/comments, e.g. colleagues working with/near you?

• Can the Task proceed safely?

  No

  Yes

• If multiple team Members are performing the task, all MUST sign off the Take 5

• Sign off

  Sign