Information
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Site
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Conducted on
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Prepared by
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Location
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Number of Urbandale Workers
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Number of Sub trade Workers
Environmental Hazards
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- Spill Potential
- Weather Condition
- MSDS's / Eyewash
- Ventilation / Inhalation
- Heat / Cold Stress
- Other Workers in Area
- Cuts / Sharp Edges
- Inadequate Lighting
- Housekeeping / Hygiene
- Poor Access / Egress
- UV Exposure / Chemical Burns
- Barricades / Guardrails
Ergonomic Hazards
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- Working in Tight Areas
- Working Above Your Head
- Repetitive Moition
- Pinch Point / Workstation
- Overexertion / Awkward
- Back / Knee Stress / Pulling
- In Line of Fire
- Confined Space / Water
- Lifting / Carrying / Pushing
- Rigid Postures / Vibration
- Overloading Spine / Joints
- Ladders / Platforms
Personal Limitations Hazards
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- Instructions Clearly Understood
- Trained to Use Tool and Perform Task
- Distraction in the Work Area
- Working Alone (communications)
- Lift Heavy/Awkward Position
- External Noise Levels / Hearing
- Physical Limitations / Positioning
- Visibility / Accessibility
- Respirator Fit Test
- Reversing Vehicles /Traffic
- Safety Compliance / Signage
- Area Secure / Whipchecks
Activity Hazards
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undefined
- Grinding / Welding
- Burn / Heat / Spark Sources
- Compressed Gases
- Energized Equipment / Cords / Tools
- Operator Seat Belts
- Equipment Guards / Parts
- Lockout / Black / Block / Blind
- Airborne Particles / Smoking
- Critical Lift / Move / Placement
- Slip / Trip Potential
- Scaffolds / Toe Boards
- Proper Rigging / Tag Lines
- Working at Heights
- Personal Protective Equipment
- Confined Space
Concerns & Follow Up Action
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Concerns
Attendance
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Name Of Supervisor
Name of Worker
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Name of Worker
