Information
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Take 5: Lifesaving Behaviors
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Prepared by
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Conducted on
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Sales Order #
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Location City/State
Take 5 Assessment
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For any failed response (noted in red) please explain in the box below the question. i.e. Can I put controls in place to manage this hazard? Attachments may be added if necessary, to better explain the situation.
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1. Can I stand clear of the danger Zone from unstable / suspended loads?
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2. Can I follow my lifting plan: No Plan, No Lift?
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3. Have I inspected my rigging, and is it suitable for this lift?
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4. Can I check that my interlocks and guarding work correctly on my equipment and I never bypass them?
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5. Can I position myself in a safe zone in relation to moving equipment?
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6. Can I protect myself against falls from height?
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7. Can I verify isolation - lock, tag, and try - when work involves hazardous energy?
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8. Can I obtain authorization and validate air quality before entering a confined space?
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9. Can I wear my seat belt?
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10. Have I PAUSED and ask for help from my supervisor if a condition is not safe or I cannot take these actions. If a near miss occurs, I report it immediately?
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11. Can I work safely in the present weather conditions? (weather, heat, etc.) Can I prevent spills and other environmental hazards?(oil spills, aerosols, etc. )
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12. Do I have the proper PPE (Personal Protective Equipment) to do my job safely?
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If additional hazards are present or possible, please explain:
