Worker Assessment Checklist

• Worker Name (first & last)

• Worker Occupation

• Date of assessment

  Date

• New / Returning Worker

• Monthly Assessment

• Worker Observation

• Worker assessment to be completed once per worker per month. This checklist should also be used to assess a new hire or a returning worker that has been away from the job for more than 6 weeks. Check appropriate boxes if "unsafe" or mark N/A. If "unsafe", provide corrective action comments for worker.

• Location
  Address

Company Policies & Procedures

Emergency Response Plan (ERP)

• Can locate ERP

  Yes

  No

  N/A

• Knows personal location on a map

  Yes

  No

  N/A

• Can identify "Safe" areas

  Yes

  No

  N/A

• Can identify FA attendant(s)

  Yes

  No

  N/A

• Has appropriate FA equipment

  Yes

  No

  N/A

Safe Work Procedures for task

• Can identify workplace hazards

  Yes

  No

  N/A

• Is alert and focused on job

  Yes

  No

  N/A

• Demonstrates safe use of tools & equipment

  Yes

  No

  N/A

• Demonstrates Lock-out procedures

  Yes

  No

  N/A

• Uses 3 point mount / dismount

  Yes

  No

  N/A

• Has pre-operational checklist(s)

  Yes

  No

  N/A

• Has required licence / certificates(s)

  Yes

  No

  N/A

• Demonstrates proper use of seat belt

  Yes

  No

  N/A

Before "clear to approach" signal given

• Stops work & makes eye contact

  Yes

  No

  N/A

• Stops all moving parts or tools

  Yes

  No

  N/A

• Lowers blade / boom / head / saw

  Yes

  No

  N/A

• Gives "clear to approach" signal

  Yes

  No

  N/A

Personal Protective Equipment (PPE)

• Hard hat of contrasting colour

  Yes

  No

  N/A

• Uses appropriate eye / face protection

  Yes

  No

  N/A

• Uses required hearing protection

  Yes

  No

  N/A

• Wears high visibility / protective clothing

  Yes

  No

  N/A

• Wears appropriate footwear for job

  Yes

  No

  N/A

Other:

• Comment

  Yes

  No

  N/A

Sign Off

• Signature of Employee / Contractor

  Sign

• Signature of Supervisor / Trainer

  Sign