WORKING AT HEIGHTS

RISK ASSESSMENT FORM

JOB TITLE	DATE ASSESSED
JOB DESCRIPTION

NATURE OF WORK:

Construction	Agriculture
Manufacturing	Material Handler
Utilities
Other:

WHO IS AT RISK? check all that apply

Employee	Contractor
Client / Customer	Members of Public
Other:

HAZARD IDENTIFIED:

Yes	No	HAZARD
Fall from height
Fall through fragile roof
Objects falling on worker(s)
Objects falling on members of public
Objects falling on resources (e.g. machinery, equipment)
Equipment supporting worker at height collapsing or breaking loose
Equipment supporting worker at height slipping/shifting around
Personnel slipping or tripping at access way for elevated equipment
Other:
Other:
Other:

CONTROL MEASURES: Attach images for visual reference

HAZARD	CONTROL MEASURE	PERSON RESPONSIBLE

OBSERVATIONS:

Yes	No	OBSERVATION	NOTES
Have workers been safely trained in safe working methods?
Are items in the work area properly stored away to minimize tripping hazards?
Have all workers at height been determined to be competent, or supervised by someone who is?
Do contractors provide documentation to verify they have been screened and properly trained?
Are contractors supervised or monitored by a competent person?
Are safety harnesses, safety nets, and other safety equipment used provided and inspected on a regular basis?
Are ladders, lifts, and other elevated equipment used provided and inspected on a regular basis?

RECOMMENDATIONS

INSPECTOR NAME	SIGNATURE	DATE INSPECTED

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