Worker Assessment Checklist - Nootka Sound Timber

• Worker Name (first & last)

• Worker Occupation

• Date of Assessment

  Date

• New / Returning Worker

• Monthly Assessment

• Worker Observation
• Location
  Address

• 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.

• If "Unsafe" add comments and/or photographs. If all items safe, select "Safe" from pull down arrow to the right.

Emergency Response Plan (ERP)

• Can locate ERP

  Safe

  Unsafe

  N/A

• Knows personal location on map

  Safe

  Unsafe

  N/A

• Can identify "Safe" areas

  Safe

  Unsafe

  N/A

• Can identify FA attendant(s)

  Safe

  Unsafe

  N/A

• Has appropriate FA equipment

  Safe

  Unsafe

  N/A

Safe Work Procedures for task

• Can identify worksite hazards

  Safe

  Unsafe

  N/A

• Is alert and focused on job

  Safe

  Unsafe

  N/A

• Demonstrates safe use of tools & equipment

  Safe

  Unsafe

  N/A

• Demonstrates Lock-out procedures

  Safe

  Unsafe

  N/A

• Uses 3 point mount / dismount

  Safe

  Unsafe

  N/A

• Has pre-operational checklist(s)

  Safe

  Unsafe

  N/A

• Has required licence / certificate(s)

  Safe

  Unsafe

  N/A

• Demonstrates proper use of seat belt

  Safe

  Unsafe

  N/A

Before "clear to approach" signal given

• Stops work & makes eye contact

  Safe

  Unsafe

  N/A

• Stops all moving parts or tools

  Safe

  Unsafe

  N/A

• Lowers blad / boom / head / saw

  Safe

  Unsafe

  N/A

• Gives "clear to approach" signal

  Safe

  Unsafe

  N/A

Personal Protective Equipment (PPE)

• Hard hat of contrasting colour

  Safe

  Unsafe

  N/A

• Uses required hearing protection

  Safe

  Unsafe

  N/A

• Uses appropriate eye / face protection

  Safe

  Unsafe

  N/A

• Wears high visibility / protective clothing

  Safe

  Unsafe

  N/A

• Wears appropriate footwear for job

  Safe

  Unsafe

  N/A

Other:

• Comment

  Safe

  Unsafe

  N/A

Sign Off

• New worker is competent to perform assigned duties under normal supervision

• Signature of Supervisor / Trainer

  Sign

• Signature of Employee/ Contractor

  Sign