Professional Documents
Culture Documents
Time:
Temp:
Wind:
Weather:
Work Surface:
III. Identify the access and egress for employees, equipment and materials._______________
_________________________________________________________________________
IV. Identify the Equipment, tools, materials, concealed hazards and physical conditions in the area that may be
or can be hazardous to the employee(s).
( ) trip hazards ( ) JLG () temperature () holes in floor
( ) dust ( ) loose grating () mists () vapors
( ) falling objects ( ) forklifts () contaminants () ice
( ) slippery surfaces ( ) cranes () motors/shafts () spills (product)
( ) operating equipment ( ) pinching points ( ) sharp objects () other:________
VIII. PPE required for job: hard hast, safety glasses, safety toe work boots required at all times.
( ) goggles ( ) face shield ( ) insulated blankets ( ) Flash protection/Electrical
( ) leathers ( ) hearing protection ( ) foot protection ( ) temporary lights
( ) ventilation ( ) harness/lanyard ( ) dust mask ( ) safety cable
( ) grounding clamps ( ) safety monitor ( ) other:______________________
IX. Telephone (emergency <in plant phone> dial 9-911) nearest location:______________________
X. Are any work permits required? ( ) YES ( ) NO They must be obtained and posted.
( ) energized electrical equipment ( ) restricted area ( ) confined space
( ) burn permit ( ) other:________________________
XV. Perform and thorough and detailed walk through of the area including floors above and below that may be
affected. Discuss job to be done in detail, so all involved understand job duties and conditions reviewed
on this assessment sheet.
XVI. Note hazards or concerns of crew, discuss why the assessment is necessary.______________
________________________________________________________________________________
________________________________________________________________________________
________________________________ _________________________
GST Site-Lead Signature Date
________________________________ _________________________
ADM Personnel Signature Date