FIELD LEVEL HAZARD ASSESSMENT
Checkoff the hazards that apply to this job. List the items in the hazards column, indicate the priority ranking and identify the plans to eliminate or control.
Back
Next
Save & Continue Later
Environmental Hazards
Other Notable Environmental Hazards
Monitors
Other Monitor Concerns
Ergonomics
Other Ergonomic Hazards
Overhead Hazards
Other Overhead Hazards
Access / Egress Hazards
Other Access / Egress Hazards
Rigging & Hoisting Hazards
Other Rigging and Hoisting Hazards
Electrical Hazards & Hot Work
Other Electrical Hazards & Hot Work
Personal Limitations / Hazards
Other Personal Limitations or Hazards Not Listed
PPE Requirements
Other PPE Requirements
Site Information
Other Notable Site Information
Back
Next
Save & Continue Later
Name
*
First Name
Last Name
Work to be completed
*
Permit Number
Date
*
-
Month
-
Day
Year
Date
PPE Inspected
*
Yes
No
Task Location:
*
Identify and Prioritize the tasks and hazards below, then identify the plans to eliminate/control the hazards
*
Has a pre-use inspection of tools/equipment been completed?
*
Yes
No
Warning ribbon needed?
Yes
No
Is the worker working alone?
Yes
No
If yes, explain:
Job Completion
Are all Permit(s) closed out?
Yes
No
Are there any hazards remaining?
Yes
No
If hazards are remaining, explain:
Were there any incidents/injuries?
Yes
No
If Yes, explain:
Name of Person Completing this form
First Name
Last Name
Email of Person Completing this form
example@example.com
Signature
*
Jules Management Signature
Client Representative Signature
Print
Save & Continue Later
Submit
Should be Empty: