FLHA (Field Level Hazard Assessment)

Sample Form

Date

Name

Trade

Jobsite

Company Name

Supervisor

Shift

Days

Afternoons

Nights

Time

First Shift

After 1st Coffee

After Lunch

After 2nd Coffee

Changes in Tasks?

Yes

No

If yes, what new task(s) are you performing? Please select below areas identified with new task(s)

Environmental Hazards

2. Material Storage Identfied

Yes

No

1. Work Area Clean

Yes

No

3. Dust/Mist/Fumes

Yes

No

4. Noise In Area

Yes

No

5. Extreme Temperatures

Yes

No

7. Waste Properly Managed

Yes

No

8. Excavaton Permit Required

Yes

No

9. Other Workers In Area

Yes

No

11. MSDS Reviewed

Yes

No

6. Spill Potential

Yes

No

10. Weather Conditions

Yes

No

17. Hands Not In Line of Sight

Yes

No

16. Lift Too Heavy/Awkward to Lift

Yes

No

15. Working in a Tight Area

Yes

No

14. Prologed twisting/Repetitive/Bending Motion

Yes

No

13. Over Extension

Yes

No

12. Awkward Body Position

Yes

No

Ergonomic Hazards

18. Working Above Your Head

Yes

No

Access/Egress Hazards

19. Aerial Lift/Man Basket (inspected & tagged)

Yes

No

21. Ladders (tied off)

Yes

No

20. Scaffold (inspected & tagged)

Yes

No

22. Slips/Trips

Yes

No

23. Hoisting (Tools & Equipment)

Yes

No

24. Evaculation (Alarms, Routes, Muster Pnts, Ph Numbers

Yes

No

25. Confined/Restricted Space Entry Permit Required

Yes

No

Overhead Hazards

All N/A

26. Barricades & Signs In Place

Yes

No

28. Harness/Lanyard Insected

Yes

No

n/a

27. Hole Coverings Identified

Yes

No

31. Power Lines

Yes

No

30. Falling Objects

Yes

No

29. 100% Tie-off with Harness/Anchor Ponits Identified

Yes

No

n/a

32. Hoisting or Moving Loads Overhead

Yes

No

38. Critical Lift Permit Required

Yes

No

37. Others Working Above/Below

Yes

No

36. Equipment Inspected

Yes

No

n/a

35. Tools/Slings Inspected

Yes

No

n/a

34. Proper Tools Used

Yes

No

33. Lift Study Required

Yes

No

Rigging & Hoisting Hazards

All N/A

Electrical Hazards

All N/A

39. GFI Test

Yes

No

40. Lighting Levels Too Low

Yes

No

41. Working On/Near Energized Equipment

Yes

No

n/a

42. Electrical Cords/Tools Condition

Excellent

Good

Poor

Damaged/Broken

43. Fire Extinguisher

Yes

No

44. Hot Work/Electrical Permit Required

Yes

No

n/a

Personal Limitations/Hazards

All N/A

45. Is Procedure Available For Task

Yes

No

47. No Training for Task or Tools to be Used

Yes

No

46. Confusing Instructions

Yes

No

48. First Time Performing the Task

Yes

No

Severity (S)

Probability (P)

Imminent Danger - causing deaths, widespread occupational illness, loss of facilities.
Serious - severe injury/illness, property and/or equipment damage.
Minor - non-serious injury, illness or damage
Not Applicable

Probable - likely to occur immediate or soon.
Reasonably Probable - likely to occur eventually.
Remote - could occur at some point.
Extremely Remote - unlikely to occur.

Tasks & Risk Assessments

Controls

Task 1

Risks/Hazards

Severity

1

2

3

4

Probability

1

2

3

4

Controls

Task 2

Risks/Hazards

Severity

1

2

3

4

Probability

1

2

3

4

Controls

Task 3

Risks/Hazards

Severity

1

2

3

4

Probability

1

2

3

4

Controls

Task 4

Risks/Hazards

Severity

1

2

3

4

Probability

1

2

3

4

Controls

Task 5

Risks/Hazards

Severity

1

2

3

4

Probability

1

2

3

4

Other Tasks/Risks/Severity/Probability

PPE To Be Used

PPE to be used for today's tasks

Crew Information

Worker #1

Check if yes

Working Alone

Check if agree

Acknowledge

Worker #2

Working Alone

Acknowledge

Worker #3

Working Alone

Acknowledge

Worker #4

Working Alone

Acknowledge

Worker #5

Working Alone

Acknowledge

Worker #6

Working Alone

Acknowledge

Worker #7

Working Alone

Acknowledge

Worker #8

Working Alone

Acknowledge

Reasons why workers area working alone.

By entering your name, qualification and checking the Acknowledge box, you are agreeing to all risks, hazards and controls stated on this FLHA.

End of Shift

Check if yes for all end of shift items.

All permits closed out

Hazards Remaining

Yes

No (explain)

Any Injuries/Incidents

Yes

No (explain)

All locks removed

All areas cleaned up at end of shift

Reason

Explain what happened.

Your Signature

Option: Add an upload link to your company's health & safety policy here.

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