UTake 5

• Store Number:

• Technician:

• Work Order Number:

• Conducted on

  Date

Stop and Look

• Observe work area and surroundings

  Yes

  No

Think Through the Task

• Work scope/Procedures/JHA understood and in use

  Yes

  No

• Correct permit requirements obtained and in use

  Yes

  No

  N/A

• Correct PPE obtained and in use

  Yes

  No

• Correct Tools/Equipment used and in good order

  Yes

  No

Identify the Hazards

• Look Close (check only that apply to you)

  Select TOOL CONDITION WORKING AT HEIGHTS SLIP, TRIPS, AND FALLS LACERATIONS UNTIDY HOUSEKEEPING CHEMICAL HANDLING EQUIPMENT HANDLING MANUAL HANDLING NOISE MISSING MACHINE PARTS

  • TOOL CONDITION
  • WORKING AT HEIGHTS
  • SLIP, TRIPS, AND FALLS
  • LACERATIONS
  • UNTIDY HOUSEKEEPING
  • CHEMICAL HANDLING
  • EQUIPMENT HANDLING
  • MANUAL HANDLING
  • NOISE
  • MISSING MACHINE PARTS

• Look Wide (check only that apply to you)

  Select CONFLICTING TASK PEDESTRIAN TRAFFIC & VEHICLE TRAFFIC EMERGENCY EXITS POOR LIGHTING WORK ENVIRONMENT SPILLS AND LEAKS BLOCKED ACCESS AND EGRESS EMERGENCY EQUIPMENT DAMAGED VEHICLES ERGONOMICS

  • CONFLICTING TASK
  • PEDESTRIAN TRAFFIC & VEHICLE TRAFFIC
  • EMERGENCY EXITS
  • POOR LIGHTING
  • WORK ENVIRONMENT
  • SPILLS AND LEAKS
  • BLOCKED ACCESS AND EGRESS
  • EMERGENCY EQUIPMENT
  • DAMAGED VEHICLES
  • ERGONOMICS

• Look for the Hidden (check only that apply to you)

  Select PRODUCT AND CHEMICALS ELECTRICITY COMPRESSED GASES VAPORS INSIDE CONFINED SPACES CORROSION THERMAL (HOT & COLD) HEAT STRESS BIOLOGICAL TOXIC GASSES PHYSICAL WEIGHT BODY POSITION

  • PRODUCT AND CHEMICALS
  • ELECTRICITY
  • COMPRESSED GASES
  • VAPORS INSIDE CONFINED SPACES
  • CORROSION
  • THERMAL (HOT & COLD)
  • HEAT STRESS
  • BIOLOGICAL
  • TOXIC GASSES
  • PHYSICAL WEIGHT
  • BODY POSITION

• Hazards Controlled Before the Task is Started

  Yes

  No

• Shared Learnings with Others in Crew/Team

  Yes

  No

Do the Task Safely

• Can the job be done safely? (If no, STOP and contact your Supervisor)

  Yes

  No