Hazard Assessment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.NameSupervisor Name *Work Location *Muster Point *Description of Work *Potential Hazards / Control MeasuresIdentify environmental and task related hazards that apply, and confirm that the relevant control measures are in place. Rank the hazard risk, considering probability and severity, with the controls in place. If additional controls are necessary, detail them in the text box below.HazardBuried UtilitiesBuried Utilities – Hazard Ranking *LowMediumHighAlberta one call, maintain line clearance, emergency response plan HazardHeat (fire/burning)Heat (fire/burning) – Hazard Ranking *LowMediumHighMachine guarding, gloves, long pants, fire extinguisher HazardNew WorkerNew Worker – Hazard Ranking *LowMediumHighAdditional training, direct supervision HazardRotating EquipmentRotating Equipment – Hazard Ranking *LowMediumHighMachine guarding, no loose clothing/hair HazardHeavy LiftingHeavy Lifting – Hazard Ranking *LowMediumHighMechanical assistance, team lift, proper form, gloves and steel toed boots HazardUV LightUV Light – Hazard Ranking *LowMediumHighWork in shade, cover exposed skin, hat, sunscreen, shaded safety glasses HazardUneven Ground/SlopesUneven Ground/Slopes – Hazard Ranking *LowMediumHighSafety boots, stay attentive while moving around site HazardSlippery ConditionsSlippery Conditions – Hazard Ranking *LowMediumHighAdjust speed, rock chips/grit, stay attentive while moving around site HazardMobile EquipmentMobile Equipment – Hazard Ranking *LowMediumHighGive operator room, eye contact prior to approach HazardHeat StressHeat Stress *LowMediumHighTake breaks, work in shade, stay hydrated HazardExcavation/TrenchesExcavation/Trenches – Hazard Ranking *LowMediumHighBarricades/cones, reinforcement as required, slope edges HazardViolence/HarassmentViolence/Harassment – Hazard Ranking *LowMediumHighZero tolerance policy, have assistance readily available, remove self from situation HazardSharp ObjectsSharp Objects – Hazard Ranking *LowMediumHighEliminate if possible, gloves HazardPinch PointsPinch Points – Hazard Ranking *LowMediumHighKeep hands visible, watch hand and body position, no loose clothing/hair HazardCrush PointsCrush Points – Hazard Ranking *LowMediumHighWatch hand and body position, communicate with operator HazardTrafficTraffic – Hazard Ranking *LowMediumHighSigns/barricades/cones, buffer truck, reflective vest, remain attentive HazardChemicals/FumesChemicals/Fumes – Hazard Ranking *LowMediumHighWHMIS training, ventilation, gloves, safety glasses, respirator HazardDustDust – Hazard Ranking *LowMediumHighMinimize with water, respirator/dust mask, safety glasses HazardNoiseNoise – Hazard Ranking *LowMediumHighLimit exposure, ear protection HazardElectricityElectricity – Hazard Ranking *LowMediumHighInspect cords, use grounded plugs HazardVibrationVibration – Hazard Ranking *LowMediumHighAvoid prolonged exposure, gloves HazardStruck By Thrown ObjectsStruck By Thrown Objects – Hazard Ranking *LowMediumHighMachine guarding, remove potential projectiles, safety glasses, long pants HazardTrip HazardsTrip Hazards – Hazard Ranking *LowMediumHighClean work area, remove unnecessary tools/equipment/waste, mark with paint/flagging tape If additional hazards are present, list them and the appropriate controls in the text box. HazardOtherOther Hazard(s) – Hazard Ranking *LowMediumHighOther Hazards and ControlsTool Box MeetingWrite notes from your daily safety discussion about the work site and work to be done.Tool Box Meeting Notes *Health and SafetyNearest Hospital to Site *MAKE A SELECTIONStrathcona Community Hospital (Sherwood Park)Royal Alexandra Hospital (North Central Edmonton)University of Alberta Hospital (South Central Edmonton)Misericordia Community Hospital (West Edmonton)Northeast Community Health Centre (Northeast Edmonton)Grey Nuns Community Hospital (Southeast Edmonton)Sturgeon Community Hospital (St. Albert)Fort Saskatchewan Community HospitalWestview Health Centre St. Albert)Devon General HospitalLeduc Community HospitalAlberta OH&S *1-866-415-8590Police / Fire / Ambulance *911Emergency Contact – Internal *Office – (780) 922-4619Darren – (780) 777-9583SignaturesHow many employees are present? Selected Value: 0 Employee #1 Name *First Aid *YesNoEmployee #1 Signature * Clear Signature Employee #2 Name *First Aid *YesNoEmployee #2 Signature * Clear Signature Employee #3 Name *First Aid *YesNoEmployee #3 Signature * Clear Signature Employee #4 Name *First Aid *YesNoEmployee #4 Signature * Clear Signature Employee #5 Name *First Aid *YesNoEmployee #5 Signature * Clear Signature Employee #6 Name *First Aid *YesNoEmployee #6 Signature * Clear Signature Employee #7 Name *First Aid *YesNoEmployee #7 Signature * Clear Signature Employee #8 Name *First Aid *YesNoEmployee #8 Signature * Clear Signature Employee #9 Name *First Aid *YesNoEmployee #9 Signature * Clear Signature Employee #10 Name *First Aid *YesNoEmployee #10 Signature * Clear Signature Employee #11 Name *First Aid *YesNoEmployee #11 Signature * Clear Signature Employee #12 Name *First Aid *YesNoEmployee #12 Signature * Clear Signature Submit