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Job Hazard Assessment Form 7

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10 views3 pages

Job Hazard Assessment Form 7

Jhaf

Uploaded by

cdykdwpzs5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Number: OH&S 18.26.

Pre-Lift Job Hazard Assessment


Printed copies of this document are uncontrolled.
Date of Lift: 34T

Machinery & Lift Description:


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Machinery & Lift Location:


__________________________________________________________________________________________
__________________________________________________________________________________________

Name of student(s)
(print)____________________________________________________________________________________
__________________________________________________________________________________________

Instructor (print)________________________________________________

Signature of Instructor___________________________________________

SITE ASSESSMENT:
Site Condition: ☐ Workspace: ☐
Surface condition, Weather, lighting, Noise Ventilation Cramped, awkward, limited access
Gas / Chemicals: ☐ Heights / Falls: ☐
Caustics, Acids, Chemical Burns, Solvents Guardrails; Slipping & Tripping; Fall Restraint Or Arrest;
Housekeeping: ☐ Emergency: ☐
Aisle Ways, Doors, Exits Clear, Trip / Slip Hazards Showers/Eye Wash Locations, Department Evacuation, Mill Evacuation, and Muster
stations

SELF ASSESSMENT:
PPE: ☐ Ergonomics: ☐
Hardhat, Boots, Gloves, Eyewear, Proper Clothing, Face Shield, Lifting Assistance, Repetitive Motion, Work In Awkward Position

Other: ☐
Balance, Traction, Grip, Stress, Frustration, Rushing, Complacency

JOB ASSESSMENT
Safe Work Procedures: ☐ Lock Out: ☐
Area or Job Specific Procedures Personal Locks, Lockout Points Stored Energy (Air, Hydraulics, Electrical, Gravity)
Fire / Hot Work: ☐ Tools / Machinery: ☐
Fire Extinguishers, Hot Work Permits, Report All Fires Hand tools are Good Condition, Power Tools In Good Condition, Inspect Before Use,

Cranes/Rigging/Lifting: ☐
Logbook Completed, Pre Use Inspection,
Proper Lifting & Rigging Equipment, Load Rate, Person in Charge,

OH&S 18.26.2 – Pre-Lift Job Hazard Assessment Form Date: 10/22/2014


PART C – Risk Assessment (To be completed by supervisor of area for any hazard, near miss or injury which necessitated or
had the potential for medical treatment or resulted in lost time) RISK RANKING: [Use Matrix]
Step 1 – Consider the Step 2 – Consider the Step 3 – Calculate the Risk
Consequences Likelihood 1.Take step 1 rating and select the Low ☐ Medium ☐ High ☐
What are the consequences of this incident What is the likelihood of the correct column
occurring? Consider what could consequence identified in 2.Take Step 2 rating and select
reasonably have happened as well as what step 1 happening? Consider the correct line
actually happened. Look at the this without new or interim 3. Circle the risk score where
descriptions and choose the one most controls in place. Look at the the two ratings
suitable. descriptions and choose the cross on the matrix below.
E=Extreme, H=High, M=Medium, L=Low,
CONSEQUENCES one most suitable.
N=Negligible
LIKELIHOOD
Consequence Description Likelihood Description CONSEQUENCES
Maj Mod Min Ins
Major Death or extensive A Is expected to occur
injuries A E E H M
B Could probably occur

LIKELIHOOD
Moderate Medical treatment B E H M M
C Could occur, but only
Minor First aid treatment rarely C H M M L
Insignificant No treatment D may occur, but probably
never will. D M M L N

Controls to reduce risk: ____________________________________________________________________


_________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Site Assessment: Notes______________________________________________________________________


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Lift Assessment: Notes ______________________________________________________________________


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Lift Changes /Alterations: Notes _____________________________________________________________


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

PLEASE RETURN COMPLETED PRE-JOB HAZARD ASSESSMENT FORMS TO YOUR INSTRUCTOR.

OH&S 18.26.2 – Pre-Lift Job Hazard Assessment Form Date: 10/22/2014


Indicate locations of blocking and jacking utilized in the job.
- List blocks and jacks: identify name and load ratings
- _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

OH&S 18.26.2 – Pre-Lift Job Hazard Assessment Form Date: 10/22/2014

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