Working Alone Job Hazard Assessment
Date of Lone Work
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
A new assessment must be completed each day lone work is performed
Name of Lone Worker
First Name
Last Name
Lone Worker Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Lone Worker
example@example.com
Manager of Lone Worker
Manager Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Project Name
Address/Driving Directions to Worksite
GPS Location of Worksite
Hazardous Activities
Restricted activities when Working Alone
Contact/Communication Ledger
Emergency Action Plan
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