Hazard Assessment
Assessment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Assessment
Describe job that assessment is being conducted for.
Conducted By
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Types of Hazards present in the job
Rows
Hazard Present
Risk Level
Mitigation
Dropped objects
High
Medium
Low
Flammable atmosphere
High
Medium
Low
Falls from height
High
Medium
Low
Slips/Falls same height
High
Medium
Low
Caught By
High
Medium
Low
Struck by
High
Medium
Low
Uncontrolled Pressure
High
Medium
Low
H2S
High
Medium
Low
Cuts/Laceration
High
Medium
Low
Electrical shock
High
Medium
Low
Chemical exposure
High
Medium
Low
Temperature
High
Medium
Low
Excessive noise
High
Medium
Low
Egress
High
Medium
Low
Security
High
Medium
Low
Vehicle Traffic
High
Medium
Low
Weather
High
Medium
Low
Additional Comments
Personal Protective Equipment (PPE) required for the job
Rows
Yes
PPE to Be Used
Head protection
Eye protection
FR Clothing
Foot Protection
Hearing Protection
Hand protection
Personal fall protection
Face protection
Respiratory protection
Electrical protective equipment
Assessment Conducted by
First Name
Last Name
Assessment Conducted By:
Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Print Form
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