• Please complete the following FLRA, to identify any hazards and/or risks around you, if you do, please support the risk reduction process by addressing this immediately.
    If this can not be achieved, please escelate this to your manager after consulting with the customer and advising of your actions.
    Think Safe, Work Safe, Home Safe

Customer Information

  • Date and Time:

  • Customer:

  • Team Member Name:

  • Additional Team Members:

  • Job Location:

  • Job Description:

  • Job Type:

  • Have you reported in?

  • Are you aware of the customers site safety rules, emergency procedures and rescue plans if working at height?

  • Are there any site specific HSE policies, programs, or procedures at the job site that you are required to follow?

  • Scaffolding

  • Overhead work/Red Zone

  • Lock Out Tag Out

  • Working at Heights

  • Hot Work

  • Confined Spaces

  • Rigging

  • Other

  • Describe the program

  • Have you made the customer aware lone working is not permitted?

Emergency Information

  • Enter all emergency contact information for the job

  • Fire

  • EMT

  • Police

  • Security

  • Enter emergency information or locations

  • Safety Data Sheet

  • Eye Wash

  • Safety Shower

  • First Aid Kit

  • Evacuation Rally Point

Risk Assessment

  • Are you and the equipment in a safe and suitable environment?

Hazard Identification

  • Indicate all hazards present at the job site:

  • Fall from heights

  • Heat stress

  • Debris

  • Lock Out Tag Out

  • Hot Work

  • Struck by/against

  • Pinch points

  • Open pits

  • Chemical exposure

  • Electrical hazards

  • Flying objects

  • Work environment

  • Material handling equipment

  • Motor vehicles

  • Are there other hazards present that are not listed above?

  • Describe hazards not listed

  • Describe controls put in place to manage hazards:

  • If there are any hazards that cannot be controlled, contact your supervisor before proceeding.

Personal Protective Equipment

  • Are you equiped with the suitable PPE?

  • Fall Protection

  • What type or model

  • Head Protection

  • What type or model

  • Eye

  • What type or model

  • Face

  • What type or model

  • Foot

  • What type or model

  • Hand

  • What type or model

  • Respirator

  • What type or model

  • Hearing

  • What type or model

  • Electrical Safety

  • What type or model

  • Fire Retardant Clothing

  • What type or model

  • Customer Specific PPE

  • What type or model

  • Other

  • What type or model

Tools and Equipment

  • Do you have all the necessary tools/equipment to work safely?

  • Prior to use, all tools and equipment must be inspected. This includes , but not limited to: electrical cords, rigging, ppe, and other safety equipment. Has this been completed?

  • Are any power tools to be used in a good and safe condition?

Lock Out Tag Out

  • Does the activity require the need for Lock Out/Tag Out of the machine or associated parts?<br>If YES is answered here, please follow next set of questions.

  • LOTO - What steps have you taken to identify the hazards and stored energey to protect yourself and others from high risk of Serious Injury or Fatality (S.I.F.)?

  • LOTO - What service is being performed that requires Lock Out/Tag Out?

  • LOTO - List the actions that you have taken to the verify the Lock Out/Tag Out of all identified hazardous energy sources.

  • LOTO - Once you have completed the service/maintenance of the machine, what steps have you taken to remove all the Lock Out/Tag Out devices?

Workplace Assessment

  • Is there sufficient natural light/arificial lighting to work safely?

  • Is there fire protection measures in place?

  • Have all precautions been taken to prevent fire, electrocution, burn, drowning, falls, crushing, trapping any other health risks?

Environmental Impact

  • Are you aware of local environmental procedures for oil spillages, pollution, noise etc?

  • If using hazardous substances, do you have all the relevant safety data sheets and hazardous information?

  • Will this job have potential to generate waste?

  • List waste generated

  • List method of disposal

  • Ensure customer is aware of potential waste generation and disposal method.

Mobile Equipment

  • Is all lifting equipment certified and in test period, is it also suitable for the job?

  • Are you or other personnel suitably qualified to operate any of the crane/equipment in use?

Final Steps

  • During your risk assessment have you identified any Serious Injury, Life altering or Fatal hazardous conditions?

  • WARNING - If you are not able to answer YES to any of the above questions, PAUSE, ASSESS and RESOLVE the issue with the customer. If this is not possible then escalate this to your relevant supervisor/manager.

  • If you identify any risks/hazards that needs attention please take a photo and include them here

  • Terex Team Member Print Name:

  • Add signature

  • Please either select "Today" or manually input the date and time

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.