CONTRACTOR

Job Risk Assesment

Date:

Shift:

Identify & evaluate job risks, exposure, hazard & potential energy, then mitigate them through the hierarchy of control

Complete this, form at the job site with all involved employees. If conditions change, STOP work & review with all involved.

Equipment #:

Work Area:

Job Description:

WO #:

Routine

Non-Routing

Is there an SOP for the job?

Yes

No

Was the SOP reviewed?

Yes

No

Fatal Risk Management Circle those that apply

Blasting

Confined Space

Contact with Electricity

Contact with Electricity

Drowning

Entanglement and Crushing

Entanglement and Crushing

Hazardous Substance-Acute

Hazardous Substance - Acute

Hazardous Substance - Chronic

Hazardous Substance - Chronic

Fall from Heights

Fall from Heights

Falling Objects

Falling Objects

Fire

Ground Failure

Lifting Operations

Lifting Operations

Rail Collision

Rail Impact on Person

Rail Collision

Uncontrolled release of Energy

Uncontrolled release of Energy

Vehicle Collision or Rollover

Vehicle Collision or Rollover

Vehicle Impact on Persons

Vehicle Impact on Persons

Additional Hazard Identification Only mark those that apply

Work Environment

Are there any elements or condtions in the work environment that could injure you or others?

Illumination / Visibility
Engulfment
Noise
Wildlife / Insects
Highwalls / Slopes
Weather
Water
Dust
Atmosphere (H2S, CO2, air, mist etc.)

Other:

Energy Sources

Have all potential energy sources that may injure you or others been identified

Electricity
Radiation
Hydraulic
Mechanical
Pneumatic / Air
Gravity
Thermal Chemical / Corrosive
Store / Under Pressure Explosive

Other:

Line of Fire

Will any proximity to work, movement, release or change in condition cause you or others injury?

Overhead Work
Fly Metal
Power Lines / Cables
Arc Flash / Blast
Material Handling
Objects in Motion
Trenching / Excavating
Pipe Handling
Tooling Failure
Mobile Equipment
Constricted Work Area
Congestion / Traffic

Other:

Personal / Behavior

What personal conditions, action or thoughts like complacency could result in injury to you or others?

Slips / Trips / Falls
Housekeeping
Sprain / Strain
Training / Competence
Ascending / Descending
Communications
Pinch Points: Hand, Body
Equipment Interaction
Footing / Uneven Ground
Fatigue
Ergonomics
Hydration

Other: