Working Alone Assesment

• Employee Working Alone

• Designated Contact Person

• Location
  Address

• Conducted on

  Date

• Prepared by

Timeframe

• Start Time

  Date

• Expected End Time

  Date

• If expected duration is greater than 2 hours a check-in is required every 2 hours.

Hazard Inspection

• Identify all hazard that may be encountered during the working alone period

Hazard

• Hazard

• Control

• Is the hazard control in place?

Check-in Records

• Worker will check in with designated contact at minimum every 2 hours and at end of working alone period

Check-In

• Contact

• Select date

  Date

• Has the working alone period ended?

• In the event the worker does not establish contact, the designated contact will try to establish contact with the worker (communication device). If unable to do so the designated contact will contact emergency services.
  
  Designated contact must not enter a confined space, or work area where the hazard has not been identified and controlled.