Task Assessed:  

Positions Considered:  

Date:  
 

Assessment Team:

FHA #:

Revision #:  

Referenced Legislation:

                          Non Mitigated:

Specialized PPE or Equipment:

Use standard PPE

Severity:

1.Negligible/OK:  Causing minor injury that requires first aid or less

2.Minor:  Causing non-serious injury, illness, or damage that requires medical aid

3.Serious: Causing severe injury, serious illness, that is disabling or lifelong, or property and equipment damage

4.Imminent danger: Causing death, widespread occupational illness, or loss of facilities

Probability:

1.Extremely Remote:  Unlikely to occur

2.Remote:  Could occur at some point

3.Reasonably Probable:  Likely to occur eventually

4.Probable:  Likely to occur immediately or soon

 
                                    Mitigated:

Hazards Associated with Task

Existing Hazard Controls

Eng:

Admin:  

PPE:  

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PPE:  

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PPE:  

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PPE:  

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PPE:  

Eng:

Admin:        

PPE: