FLHA (Daily Field Level Hazard Assessment)

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How many workers are included on this FLHA?
The supervisor listed on this form will receive a copy of this FLHA via email upon submission. If anyone else requires a copy, enter email in the box below.
Other Email Recipient:
example@example.com
Worker 1: *

First Name Last Name
Worker 1: *
Worker 2: *

First Name Last Name
Worker 2: *
Worker 3: *

First Name Last Name
Worker 3: *
Worker 4: *

First Name Last Name
Worker 4: *
Worker 5: *

First Name Last Name
Worker 5: *
Worker 6: *

First Name Last Name
Worker 6: *
Worker 7: *

First Name Last Name
Worker 7: *
Worker 8: *

First Name Last Name
Worker 8: *
Worker 9: *

First Name Last Name
Worker 9: *
Worker 10: *

First Name Last Name
Worker 10: *
Worker 11: *

First Name Last Name
Worker 11: *
Worker 12: *

First Name Last Name
Worker 12: *
Worker 13: *

First Name Last Name
Worker 13: *
Worker 14: *

First Name Last Name
Worker 14: *
Worker 15: *

First Name Last Name
Worker 15: *
Worker 16: *

First Name Last Name
Worker 16: *
Worker 17: *

First Name Last Name
Worker 17: *
Worker 18: *

First Name Last Name
Worker 18: *
Worker 19: *

First Name Last Name
Worker 19: *
Worker 20: *

First Name Last Name
Worker 20: *
Supervisor or Crew Lead Information
Supervisor's Name: *

First Name Last Name
Supervisor's Email:
(Must enter to receive a copy)
Supervisor Signature: *
Are there any additional workers that need to sign onto this FLHA?

Yes No

Please answer the following and leave any comments as required:

	Yes	No	Comments/Notes
Are all permits closed out?
Are there hazards remaining?
Was the area cleaned up at the end of job/shift?
Were there any incidents/injuries that occurred today?

Please complete the necessary form(s):

Incident Notification Report

Hazard ID/HSE Opportunity/Near Miss Report

First Aid Record
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?
Additional Worker 1: *

First Name Last Name
Additional Worker 1: *
Additional Worker 2: *

First Name Last Name
Additional Worker 2: *
Additional Worker 3: *

First Name Last Name
Additional Worker 3: *
Additional Worker 4: *

First Name Last Name
Additional Worker 4: *
Additional Worker 5: *

First Name Last Name
Additional Worker 5: *
Should be Empty:

	Yes	No	Notes/Explanation
Are there any other specific hazards?
Will work affect traffic?
Will traffic cause hazard to the work area?
Are others on job site aware of your job procedure
Has client orientation been conducted?
Have the proper precautions been taken for the above hazards?

Ground Disturbance

	Yes	No	Comments/Notes
Has a pre-use inspection of tools/equipment been completed?
Is warning ribbon needed? If yes, please describe why.
Are any workers working alone? If so, please mention their check-in plan.