Field Level Hazard Assessment

Field Level Hazard Assessment
Please complete the FLHA prior to start of each task or change in conditions.
Date

DayMonthYear
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

Spill PotentialWaste Containers NeededWaste Properly DisposedWaste Plan IdentifiedOther Workers In AreaWeather ConditionsSDS Reviewed
Access / Egress Hazards

Scaffold (Inspected and tagged)Ladders (Inspected and Tied Off)Slips / TripsHoisting (Tools, Equipment)Evacuation (Alarms, Routes, Phone #'s)Confined Space Entry Pemit Required
Rigging Practice Hazards

Lift Study RequiredProper Tools UsedTools InspectedEquipment InspectedProper Slings (Inspected)Others Working Overhead / BelowCritical Lift Permit
Ergonomic Hazards

Awkward Body PositionOver ExtensionProlonged Twisting / Bending MotionWorking in Tight AreasLift too Heavy / Awkward LiftParts of Body in Line of FireRepetitive MotionHands Not in Line of SiteWorking above Your Head
Electrical Hazards

Lockout Procedures In PlaceGFI TestLighting Levels Too LowWorking On / Near Energized EquipmentElectrical Cods ConditionElectrical Tools ConditionFire ExtinguishersHot Work Permit RequiredGround Disturbance
Overhead / Electrical Work Hazards

Barricades and Sign in PlaceHole Covering IdentifiedHarness / Lanyard Inspected100% Tie-offTieoff Points I.D.Falling ItemsForeign Bodies in EyesHoisting or Moving Loads Overhead
Ensure PPE Requirements

Hard HatSafety GlassesGlovesCSA BootsCoverallsHearning ProectionAddtion PPE Required
Personal Limitations / Hazards

Procedures Not Available for TaskConfusing InstructionsTrained To Use Tools and Perform TaskFirst Time Performing TaskDistractionsMicro Brek Required
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

YesNoN/A
Warning ribbon removed

YesNoN/A
Are permits closed out

YesNoN/A
Area cleaned up at end of job/shift

YesNo
Hazards Remaining

YesNo
Was there any injuries or accidents

YesNo
If Yes please explain
List all workers present during the work tasks discussed as a group.
Workers Name
Workers Name
Workers Name
Workers Name
Please sign below declaring you have fill out this form to the best of your ability.
Signature
Should be Empty: