Hazard Assessment Form

Department / Work Type

Company Name and Project

Work Location and Muster Point

Today's Date

Date

Time

:HourMinutesAM/PM Option

Environmental Hazards

Rows	Hazard Present	N/A
Weather Conditions
SDS Reviewed
Ventilation
Heat or Cold exposure
Lighting Levels too low
Housekeeping
Hazardous Chemical Exposure

Work Activity Hazards

Rows	Hazard Present	N/A
Hand Tool Use
Burn/Heat Sources (Grinding or Welding)
Energized Equipment
Scaffolding
Ladders
Noise Hazards (85 Decibels)
Workers Below or Overhead

Ergonomics Hazards

Rows	Hazard Present	N/A
Pinch Points
Consistent Repetitive Motion
Awkward Body Position or Movement
Lifting - Heavy or Awkward Load
Working Above your Shoulders
Working in Tight Areas

Access/ Egress Hazards

Rows	Hazard or Control Present	N/A
Doors/ Stairs or Hallways Obstructed
Slip/ Trip Potential
Extension Ladder 3' Above Roof/Ledge
Evacuation/ Muster Point Identified

Height Hazards

Rows	Hazard Present	N/A
Ladders Required
Protect from Falling Items
Warning Signs, Flagging or Barricades
Fall Arrest System in place
Scaffold Inspected/ Checked

Procedures/ Documenation

Rows	Procedure Reviewed	N/A
Pre Use Inspections (Tool/PPE/Equipment)
Unloading cages / Loading cages
Standing Walls
Ladders/Finishing
Other

PPE Requirements

Rows	Required	N/A
Safety Glasses (Correct Type)
Face Shields
Gloves (Correct Type for Hazard)
Hearing Protection
Dust Mask or Respirator
Hard Hat (Correct Type for Hazard)
Fall Protection
Winter Clothing/ Rain Gear/ Summer Clothing
CSA Approved Work Boots (Steel Toe, Composite or Work Boots- As per site requirements)

Site Safety / Foreman's Kit

Rows	Compliant	NA
Eyewash bottles and First Aid Kit

*In This Section Complete The Task, Hazard And Control for each section.

Task

Write Tasks ie: 1- Unload cages etc.

Hazard

Write Hazards ie: 1- Cages can cause crush hazards etc.

Controls

Write Controls ie: Use safe lifting techniques, PPE and Engineering Control. etc.

Additional Information

Comments:

Add a Photo of Site Conditions, Hazard or Concern

Photo Comment:

Employee or Worker Name

Supervisor Review of Hazard Assessment

Signature

Email

example@example.com

Email

example@example.com

Safety is crucially important and must be taken seriously to prevent incidents to you, your co-workers and property. Please ensure all hazards, concerns and near misses are identified and reported to your supervisors prior to working.

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