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Ground Disturbance for Supervisors
Hazard Assessment and Control Form
The Facilitator or Lead of Hazard Assessment is to fill out all the sections of this form. Information is to be printed and
legible. All changes and corrections are to be initialled and dated.
Date: Location:
Scope of work for risk review:
Hazard assessment leader:
Attendees:
Potential hazards: Refer to the list on pages 3-5.
List of Hazards and Controls
Hazard Safety or Pre-Control Risk Controls Mediated Action Completed by
Health Risk Risk Rank Risk Rank
Elim:
Eng:
Admin:
PPE:
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Supplementary Information
Reference Documents (Standards, Procedures, Codes, etc.)
Reference Excerpt
Acknowledgment and Signatures
By signing this form, you acknowledge that you understand the hazards and how to apply the methods to eliminate
or control them.
Name Signature Name Signature
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Potential Hazard List
This list gives Hazard Assessment participants some ideas for potential hazards. The Hazard Assessment and Control
team should use this list as a starting point to help identify potential hazards.
Note: This is not a comprehensive list.
Permits/Procedures Lifting
• Have permits and procedures been reviewed with • Are workers aware of their body positions while
the crew? doing manual lifting?
• Have permit conditions been met? • Do tools/materials require hoisting?
PPE • Are proper rigging practices applied?
• Is the required PPE available? • Is the equipment in good condition?
• Are workers trained in the use of the PPE? Emergency Preparedness
• Was the PPE inspected and in good condition? • Have first aiders been identified?
• Is the required PPE identified and utilized? • Have communication systems /procedures been set?
• Is specialized PPE available? • Have working-alone procedures been set?
• Is hand protection available? • Have evacuation routes, assembly areas and
meeting points been determined and identified?
• Are boots in good shape and well-maintained?
• Have eyewash stations, emergency showers,
• Is loose clothing secured or replaced?
fire extinguishers, trauma kits, and other safety
Tools
equipment been checked?
• Are proper tools available for the job?
Access and Egress
• Have tools been inspected before use?
• Is a confined space entry required?
• Are manufacturer’s guards on equipment?
• Has scaffolding been inspected and tagged?
• Are air hose couplings and whip checks secured?
• Are sufficient ladders available and secured?
Ergonomics
Environmental Conditions
• Does completing the task involve:
• Is there a spill potential?
• Awkward or twisting body positions?
• Are containment and clean-up procedures in place?
• Overextension?
• Are waste containers needed?
• Sustained positions?
• Repetitive motions?
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Fire and Explosion Rigging and Hoisting
• Is a fire watch needed and in place? • Has the lift been classified?
• Is compressed gas handling and control of transient • Has lifting gear been checked and found to be in
materials required? good condition?
• Have special precautions been met when • Are workers trained and competent?
working on equipment with fire detectors and • Are tag lines used when required?
protection systems?
• Do designated signal persons understand and use
• Are sewer covers present? proper hand signals?
• Are grounding and bonding used as needed? • Are loads not suspended over workers?
• Are flammables stored away from heat or • Are effective communication procedures in place?
ignition sources?
• Are equipment and rigging used within the
Working From Heights manufacturer’s safe working load (SWL)?
• Is approved fall protection used? • Is all rigging certified and with SWL labels?
• Are secure anchor points used? • Do workers know the weights of loads being lifted?
• Are guardrails, handrails, mid-rails, and toe Position of People
boards installed?
• Are workers in the line of fire?
• Are stepladders fully opened?
• Can they get out of the line of fire in an emergency?
• Are extension ladders angled at a 4:1 ratio
• Are workers maintaining a safe position with
and secured?
respect to loads, moving equipment, and limits of
• Are non-conductive ladders used near approach near electrical lines?
electrical equipment?
• Are workers avoiding hazards from grinding debris
• Are materials and equipment hoisted up? or pressure release?
• Is personal fall arrest equipment inspected • Do workers warn others of potential hazards?
before use?
• Is everyone using a three-point contact to step
• Are holes covered and marked? down from equipment or elevated surfaces?
• Do ladders extend 1.0 m above the landing? • Are warning signs and safety instructions followed?
• Do workers involved in aerial lifts have valid training?
• Is a personnel basket used, and was it inspected?
• Are air hose couplings and whip checks secured?
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Ground Disturbance Hazardous Materials Handling
• Are excavations deeper than 1.3 m adequately • Are hazardous chemicals in proper containers
sloped or shored? and labelled?
• Are spoil piles/equipment away from the trench/hole? • Are safety data sheets (SDS) readily available?
• Have underground utilities been identified? • Have WHMIS and TDG been adhered to?
• Is the digging face appropriate for the machinery • Are materials stacked securely?
and clear of overhangs? • Is spill containment available?
• Are signs or barricades around excavations? Electrical
Hazard Controls • Have extension cords been inspected?
• Are warning and hazard signs posted? • Are explosion-proof cords and tools used?
• Does the task involve overhead work? • Is work on/near energized equipment required?
• Are barricades, signs, flagging, or tagging used? • Are voltage detectors required?
• Are hole covers in place? • Is specific PPE such as HV gloves, Cat 2,
• Are hazardous areas barricaded or secured? or Cat 4 gear needed?
• Are confined spaces identified? • Is appropriate inner clothing required and worn?
• Are other safeguards in place? • Are hot sticks and grounding chains required?
Control of Hazardous Energy Weather Conditions
Have the following energies been controlled? • Snow
• Mechanical (motor, valve) • Ice
• Pneumatic (compressed air) • Heat
• Electrical (breaker panel, switches) • Cold
• Steam (boiled water) • Rain
• Chemical (battery acid) • Wind
• Thermal (high temperature, heat) • Lightning
• Hydraulic (fluid oil under pressure)
• Radiation (x-rays)
• Kinetic (anything in motion)
• Potential (stored energy)
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