Safety Hazard Assessment
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Name of assessor :
Project:
Address:
Street Address
City
State / Province
Postal / Zip Code
Number of Employees:
Start Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Eye Hazards:
Yes
No
Eye Hazards:
Description of Hazards:
Required PPE
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Next
HEAD/NECK/FACE HAZARDS:
Yes
No
HEAD/NECK/FACE HAZARDS:
Description of Hazards:
Required PPE
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Next
FOOT HAZARDS:
Yes
No
FOOT HAZARDS:
Description of Hazards:
Required PPE
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Next
HAND HAZARDS:
Yes
No
HAND HAZARDS:
Description of Hazards:
Required PPE
Back
Next
BODY HAZARDS:
Yes
No
BODY HAZARDS:
Description of Hazards:
Required PPE
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Next
FALL HAZARDS:
Yes
No
Description of Hazards:
Required PPE
Notes:
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Next
NOISE HAZARDS:
Yes
No
Description of Hazards:
Required PPE
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Next
RESPIRATORY HAZARDS:
Yes
No
Description of Hazards:
Required PPE
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Next
NOTES
Signature
Submit
Submit
Should be Empty: