Job Safety/Hazard Assessment Form

Job Info






Have all hazards been controlled or eliminated?



Crew Member Names/Signatures

All crew members must confirm their presence by adding their name to the list

Basic Task Steps












PPE Cleared and Inspected?

*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
*Severity
*Probability
Report all injuries to your supervisor

Job Completion

Warning ribbon / sign required?

YESNON/A

Warning ribbon / sign removed?

YESNON/A

Al Permits Closed out?

YESNON/A

Incedent/Injuries accued during shift?

YESNON/A