FLHA V1 (Daily Field Level Hazard Assessment)

Risk Ranking

Severity

Probability

1 = Imminent Danger (causing death, widespread occupational illness or loss of facilities)

2 = Serious (severe injury/illness, property and/or equipment damage)

3 = Minor (non-serious injury, illness or damage)

4 = Not Applicable

A = Probable (Likely to occur immediately or soon)

B = Reasonably Probable (likely to occur eventually)

C = Remote (could occur at some point)

D = Extremely Remote (unlikely to occur)

Identify and Prioritize the tasks and hazards below, rank each risk considering the health and safety hazards relating to the task, then identify the plans to eliminate/control the hazard. If a new task/hazard is added after starting work, you must edit this electronic submission to update.

Please print and sign below (All members of the crew) prior to commencing work.
Type a question
How many workers are included on this FLHA?
The first worker listed and supervisor listed on this form will receive a copy of this FLHA via email upon submission.
1st Worker's Name:

First NameLast Name
1st Worker's Email:
example@example.com
Signature of 1st Worker:
2nd Worker's Name:

First NameLast Name
Signature of 2nd Worker:
3rd Worker's Name:

First NameLast Name
Signature of 3rd Worker:
4th Worker's Name:

First NameLast Name
Signature of 4th Worker:
5th Worker's Name:

First NameLast Name
Signature of 5th Worker:
6th Worker's Name:

First NameLast Name
Signature of 6th Worker:
7th Worker's Name:

First NameLast Name
Signature of 7th Worker:
8th Worker's Name:

First NameLast Name
Signature of 8th Worker:
9th Worker's Name:

First NameLast Name
Signature of 9th Worker:
10th Worker's Name:

First NameLast Name
Signature of 10th Worker:
11th Worker's Name:

First NameLast Name
Signature of 11th Worker:
12th Worker's Name:

First NameLast Name
Signature of 12th Worker:
13th Worker's Name:

First NameLast Name
Signature of 13th Worker:
14th Worker's Name:

First NameLast Name
Signature of 14th Worker:
15th Worker's Name:

First NameLast Name
Signature of 15th Worker:
16th Worker's Name:

First NameLast Name
Signature of 16th Worker:
17th Worker's Name:

First NameLast Name
Signature of 17th Worker:
18th Worker's Name:

First NameLast Name
Signature of 18th Worker:
19th Worker's Name:

First NameLast Name
Signature of 19th Worker:
20th Worker's Name:

First NameLast Name
Signature of 20th Worker:
Supervisor or Crew Lead Information
Does anyone else need to receive a copy of this form? If yes, please enter their e-mail address here:
example@example.com
Supervisor:
Supervisor Name:
Supervisor's Email:
example@example.com
Supervisor Signature:
Are there any other workers (not part of the work crew) or contractors that need to sign onto this FLHA?

YesNo
It is important that all hazards are identified and controlled. Confirm that all permits are valid.

Remember:

"Stop & Think" & "See It Again For The First Time"

Other Workers/Contractors

Please add names and sign below all additional workers or contractors prior to commencing work.
How many additional workers would you like to include?
1st Worker's Name:

First NameLast Name
Signature of 1st Worker:
2nd Worker's Name:

First NameLast Name
Signature of 2nd Worker:
3rd Worker's Name:

First NameLast Name
Signature of 3rd Worker:
4th Worker's Name:

First NameLast Name
Signature of 4th Worker:
5th Worker's Name:

First NameLast Name
Signature of 5th Worker:

Does anyone else need to receive a copy of this form?

If not, leave blank and press submit.
The HSE Department already receives a copy of this submission. Please do not include the HSE Department as an additional email recipient.
If anyone else needs to receive a copy of this form, please enter their email(s) here:
Please separate multiple emails by a comma
If anyone else needs to receive a copy of this form, please enter their email(s) here:
Please separate multiple emails by a comma
Should be Empty:

FLHA (Field Level Hazard Assessment)

Hazard Checklist

Additional Questions:

Please print and sign below (All members of the crew) prior to commencing work.

Supervisor or Crew Lead Information

Other Workers/Contractors

Does anyone else need to receive a copy of this form?