Field Level Hazard Assessment

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"*" indicates required fields

MM slash DD slash YYYY
Time:*
:

Team Members

**Print Name & Sign

Supervisor Checklist

Workers performing task safely?*
Workers wearing all required PPE?*
Has crew Assessed hazards correctly?*
Do all workers understand the task?*
Are workers fit for duty/task?*

Have the Following Been Reviewed

Job Locations*
Special Job Procedures*
Emergency Response Plan*
Safety Data Sheet(s) – SDS*

Hazard Identification Checklist

1. Safety Orientation Completed?*
2. Job scope understood?*
3. Proper safety equipment on site?*
4. Permit Issued? What type?*
5. Oxygen/flammability check?*
6. Confined space procedure/rescue plan reviewed? Permit Signed?*
7. Electrical & Mechanical lock out procedure required?*
8. Is your lock & tag in place?*
9. Communicated work with others in area?*
10. Proper tools for job?*
11. Reviewed SDSs for any hazardous substance that might be present?*
12. Returned card to site safety/management?*

Identify Potential Hazard

**Tick All That Apply
Identify Any Potential Hazards*

Spill Prevention Measures

Review potential for a spill?
Is spill containment needed?
Is spill kit available?

Controls

At Risk Employees

New Worker?*
Job?*
Site?*

Supervisor Completion Checklist

Work area cleaned up?*
All tags and locks removed and signed off by individuals?*
Permit turned in?*
Job status communicated to management?*
Were there any incidents?*

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