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Field Level Hazard Assessment (FLHA)
Date / Time
*
Project
*
Task Location
*
Supervisor
*
Environmental Hazard(s) (copy)
*
Spill Potential / Containment
Weather Conditions
Air Quality /Ventilation
Heat Stress/Cold Exposure
Light Levels
Housekeeping
Asbestos/Mould
Silica/Dust
Environmental Hazard Related Comments:
Ergonomic / Material Hazard(s)
*
Working in tight area
Working above your head
Pinch points identified
Repetitive motion
Awkward Body Position
Over Extension
Ergonomic/Material Hazard Related Comments:
Working At Heights
*
Barricades, Flagging, and signs
Hole coverings in place
Aerial Lifts
Ladders
Fall Protection System
Others working above/below
Working at Heights Related Comments:
Activity Hazards
*
Mobile Equipment
Electrical cords/tool condition
Equipment/Tools Inspected
Compressed Gases
Confined/Restrictive Space
Working near energized Equipment
Airbourne Particles
Open Hole(s) / leading Edge(s)
Pipe Installation
Pipe Fabrication
System Testing
Material Handling
Activity Hazard Related Comments:
Access / Egress Hazards
*
Scaffold (Inspected & Tagged)
Slip & tripping potential
Access/Egress Hazard Related Comments:
Personal Limitations
*
Working Alone
Heavy and/or Awkward Lifting
Physical Limitations
Trained to use tool / perform task(s)
Personal Limitations Related Comments:
Personal Protective Equipment (PPE)
*
Footware
Head Protection (Hard Hat)
High Visibility Vest
Respiratory Protection (APR)
Clothing
Hearing Protection
Hand Protection (Gloves)
Face Protection (Face Shield)
Eye Protection
Fall Protection
PPE Inspected
Personal Protective Equipment Related Comments:
Delivery Worker 1
*
Delivery Worker 3
Delivery Worker 5
Delivery Worker 2
Delivery Worker 4
Delivery Worker 6
Email address to send copy to. (optional)
Email
Confirm Email
Name of Worker filling out this Assessment.
*
Acknowledgement
*
I hereby acknowledge that I have fully reviewed, understood, and completed the Field Level Hazard Assessment. I commit to adhering to all safety protocols, recommendations, and requirements outlined in this assessment.
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