Field Level Hazard Assessment

Please complete the FLHA prior to start of each task or change in conditions.

Date

Name of person completing form

First NameLast Name

Task

Task Location

Forman

Formans Contact #

Permit / Job # / Work Order #

Review the following with work crew at the worksite, and check the items, which only apply to the task . List them below with each job task step in the hazards column and identify the plans to eliminate or control them.

Environmental Hazards

Access / Egress Hazards

Rigging Practice Hazards

Ergonomic Hazards

Electrical Hazards

Overhead / Electrical Work Hazards

Ensure PPE Requirements

Personal Limitations / Hazards

It is important that all hazards / Concerns have action plans to eliminate or control them and that these plans are put in place prior to start of task.

Identify the task and hazards then identify the plans to eliminate or control the hazards.

*Priority for Corrective Action:

#1 - Very Hazardous #2 - Hazardous with moderate risk #3 - Low Risk #4 - O.K. #5 - Not Applicable

List all Job Task Steps

Emergency Meeting / Muster Point

Emergency #

Area CodePhone Number

Permit Reviewed

Warning ribbon removed

Are permits closed out

Area cleaned up at end of job/shift

Hazards Remaining

Was there any injuries or accidents

If Yes please explain

List all workers present during the work tasks discussed as a group.

Workers Name

Please sign below declaring you have fill out this form to the best of your ability.

Signature