FLHA (Daily Field Level Hazard Assessment)

Hazard Checklist

Select applicable items from the category dropdown lists.
Biological Hazards:
Chemical Hazards:
Communication Hazards:
Electrical Hazards:
Emergency Response Hazards:
Ergonomic Hazards:
Excavating & Trench Hazards:
People Hazards:
Procedure Hazards:
PsychoSocial Hazards:
Overhead Hazards:
Personal Limitations/Hazards:
Environmental Hazards:
System Hazards:
Physical Hazards:
PPE Hazards:

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Foreman:*
Person completing this FLHA:*
Name:*

First NameLast Name
Signature of Person Completing this FLHA:*
***DO NOT REMOVE THE OTHER OPTION FROM CREW MEMBERS LIST***
Crew Members:*
***DO NOT REMOVE THE OTHER OPTION FROM CREW MEMBERS LIST***
Other Crew Member(s):*
YesNo
List the designated work scope the temporary workers will be performing:*
Outline the designated work area where the temporary workers are authorized to perform work:*
YesNo
Please ensure you have listed all temporary worker names in the Other option on the worker names list above and that they are all signed onto the FLHA below.
Enter the number of workers to display the signature boxes for each worker.
# of Workers:
Signature:

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Access to forms if necessary:

Incident Notification Report

Hazard ID/HSE Opportunity/Near Miss Report

First Aid Record
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Should be Empty:

Severity	Probability
1 = Imminent Danger (causing death, widespread occupational illness or loss of facilities)	A = Probable (Likely to occur immediately or soon)
2 = Serious (severe injury/illness, property and/or equipment damage)	B = Reasonably Probable (likely to occur eventually)
3 = Minor (non-serious injury, illness or damage)	C = Remote (could occur at some point)
4 = Not Applicable	D = Extremely Remote (unlikely to occur)

Rows	Yes	No	Comments/Notes
Have you reviewed the ERP?
Have you reviewed the Project Specific Assessment (PHA)?
Have you reviewed the Safety Guidelines?
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 yes, please specify their check-in plan.

FLHA (Field Level Hazard Assessment)

Hazard Checklist

Hazard Assessment

Additional Questions:

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