Worksite Hazard Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Type of work being performed by Great West Resources on this site.

• Advance

  Yes

  No

  N/A

• Cutting (Saw/Mulching)

  Yes

  No

  N/A

• Surveying

  Yes

  No

  N/A

• Drilling

  Yes

  No

  N/A

Worksite information

• Project Name and GWR Job#

• Prime Contractor

• Is there an Emergency Response Plan available for this project?

  Yes

  No

  N/A

• Project Manager and Contact Information

• Other Contact People on Prime Contractor's Emergency Response Plan.

• GPS coordinates of program staging location and direction from primary lodging.

• Describe directions to nearest Hospital or Health Centre from Program Staging Location.

• S.T.A.R.S. site location, ID number and expiry

Driving Hazards

• Wildlife

  Yes

  No

  N/A

• Wet Roads

  Yes

  No

  N/A

• Icy Roads

  Yes

  No

  N/A

• Gravel Roads

  Yes

  No

  N/A

• Winter Access Roads

  Yes

  No

  N/A

• Seasonal Roads

  Yes

  No

  N/A

• Radio Access Roads

  Yes

  No

  N/A

• Steep Road Shoulder

  Yes

  No

  N/A

• Potholes

  Yes

  No

  N/A

• Railway Crossings

  Yes

  No

  N/A

• Blind Corners

  Yes

  No

  N/A

• Blind Hills

  Yes

  No

  N/A

• Steep Hills

  Yes

  No

  N/A

• Narrow Bridges

  Yes

  No

  N/A

• One Lane Bridges

  Yes

  No

  N/A

• Ice Bridges

  Yes

  No

  N/A

• Temporary Creek Crossings

  Yes

  No

  N/A

• Unmarked Intersections

  Yes

  No

  N/A

• Gates

  Yes

  No

  N/A

• Field Crossings

  Yes

  No

  N/A

• Driving in low light conditions

  Yes

  No

  N/A

• Oilfield Activity

  Yes

  No

  N/A

• Farming Activity

  Yes

  No

  N/A

• Forestry/Logging Activity

  Yes

  No

  N/A

• School Buses

  Yes

  No

  N/A

• Add any other Driving Hazards associated to driving to worksite

• How far is staging or the worksite from lodging? How long does it take to travel this distance following speed limits and restrictions?

Emergency Response Equipment required by GWR or Prime Contractor on this worksite.

• Is there a medic required on program? Refer to OH&S regulations for suggested minimums.

  Yes

  No

  N/A

• Is there a requirement for an Emergency Medical Transport Vehicle on this program?

  Yes

  No

  N/A

• Can the medic reach the extremities of the project within the time regulations?

  Yes

  No

  N/A

• Is there a requirement for a Fire Truck on the worksite?

  Yes

  No

  N/A

• Is a helicopter required or recommended for this worksite?

  Yes

  No

  N/A

• Are H2S monitors required on site?

  Yes

  No

  N/A

• Is Respiratory Equipment required on site?

  Yes

  No

  N/A

• All Great West Resources employees' vehicles MUST have First Aid Kits as well as Fire Extinguishers.

• Are emergency shut off switches required on Diesel Engines?

  Yes

  No

  N/A

• Is there any other or specialty safety equipment required or recommended on this site?

Site Hazards - Oil and Gas

• H2S

  Yes

  No

  N/A

• SO2 or burning stacks

  Yes

  No

  N/A

• Gas plants or other production facilities

  Yes

  No

  N/A

• Active Oil Wells

  Yes

  No

  N/A

• Abandoned Oil Wells

  Yes

  No

  N/A

• Oil Well Drilling or site preparation

  Yes

  No

  N/A

• High, Medium or Low Pressure Pipelines

  Yes

  No

  N/A

• Other hazardous materials

  Yes

  No

  N/A

Site Hazards - Properties

• Crown Land

  Yes

  No

  N/A

• Dwellings

  Yes

  No

  N/A

• Acreages

  Yes

  No

  N/A

• Abandoned homes or buildings

  Yes

  No

  N/A

• Water Wells

  Yes

  No

  N/A

• Sceptic Fields

  Yes

  No

  N/A

• Other Hazards related to properties

Site Hazards - Farming and Ranching

• Farm Yards

  Yes

  No

  N/A

• Abandoned Farm Yards

  Yes

  No

  N/A

• Livestock

  Yes

  No

  N/A

• Corals

  Yes

  No

  N/A

• Crops

  Yes

  No

  N/A

• Grazing Pastures

  Yes

  No

  N/A

• Humics

  Yes

  No

  N/A

• Rock Piles

  Yes

  No

  N/A

• Irrigation Ditches

  Yes

  No

  N/A

• Dugouts

  Yes

  No

  N/A

• Other Hazards related to farming and ranching

Site Hazards - Natural Hazards

• Badger Holes

  Yes

  No

  N/A

• Trees

  Yes

  No

  N/A

• Brush

  Yes

  No

  N/A

• Muskeg

  Yes

  No

  N/A

• Slough or Swamp

  Yes

  No

  N/A

• Water bodies (lakes, rivers, creeks, ponds)

  Yes

  No

  N/A

• Mountainous area

  Yes

  No

  N/A

• Cliffs

  Yes

  No

  N/A

• Hills

  Yes

  No

  N/A

• Side hills

  Yes

  No

  N/A

• Weather conditions

  Yes

  No

  N/A

• Other natural hazards

Site Hazards - General Hazards

• Buried Facilities (power, telephone, water, fibre optics....)

  Yes

  No

  N/A

• Overhead Powerlines

  Yes

  No

  N/A

• Barbwire Fences

  Yes

  No

  N/A

• Wooden Fences

  Yes

  No

  N/A

• Junk piles or abandoned large objects (cars...)

  Yes

  No

  N/A

• Railways

  Yes

  No

  N/A

• Roads crossing project

  Yes

  No

  N/A

• Ditches

  Yes

  No

  N/A

• Other general site hazards

Predatory Hazards

• Hunting

  Yes

  No

  N/A

• Trapping

  Yes

  No

  N/A

• Bears (if the type is known, please provide)

  Yes

  No

  N/A

• Felines (cougars, lynx...) precise type

  Yes

  No

  N/A

• Canines (wolves, coyotes...) precise type

  Yes

  No

  N/A

• Ungulates (deer, moose, elk...) precise type

  Yes

  No

  N/A

• Other carnivores (badgers, wolverines, weasels...)

  Yes

  No

  N/A

• Snakes

  Yes

  No

  N/A

• Other predatory hazards

Environmental Hazards

• Wind

  Yes

  No

  N/A

• Snow

  Yes

  No

  N/A

• Ice

  Yes

  No

  N/A

• Rain

  Yes

  No

  N/A

• Sun

  Yes

  No

  N/A

• Extreme Heat

  Yes

  No

  N/A

• Extreme Cold

  Yes

  No

  N/A

• Windchill

  Yes

  No

  N/A

• Flooding

  Yes

  No

  N/A

• Tornadoes

  Yes

  No

  N/A

• Avalanches

  Yes

  No

  N/A

• Blizzards

  Yes

  No

  N/A

• Insects

  Yes

  No

  N/A

• Air born or water born Pathogenes

  Yes

  No

  N/A

• Other environmental Hazards

Personal Protective Equipment required by Great West Resources

• ALL operators of off-road vehicles (ATV, Snowmobiles...) are REQUIRED to wear CSA or DOT approved helmets.

• CSA approved hard hats

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Foot Protection

  Yes

  No

  N/A

• Hand Protection

  Yes

  No

  N/A

• Personal First-Aid kit

  Yes

  No

  N/A

• Personal H2S monitor

  Yes

  No

  N/A

• Fire retardant coveralls

  Yes

  No

  N/A

• All workers are required to carry an up to date Emergency Response Plan as well as have a copy in their vehicles.

• All workers are required to carry their up to date safety tickets.

Remarks

• Is there any other pertinent information about the project?

• Are there any preoccupations about the project that require immediate action?

• Comments

• Assessor

  Sign