Employee Name

2—Work Location

3—New or Revised


4—What Is The Most Hazardous Part Of This Job And What Are You Going To Do To Control The Hazard?

5—Are You Properly Trained To Complete This Task?


7—What Do You Need To Ensure This Job Is Completed Incident And Injury Free?

8—What Conditions, Job Changes Or Distractions Could Call For The Need To Stop Work Production?

9—Sequence of Job Steps

10—Potential Hazards

11—Recommended Action or Procedure

12—Additional Personal Protective Equipment

13—Chemical Hazards

14—Hazardous Energy Equipment

15—Environmental Conditions

16—Tools And Equipment


Examine Each Step Carefully To Find And Identify Hazards Or Potential Dangers That Could Lead To Injury,
Illness Or Damage, Consider The Following:

17—Chemical Hazards

18—Biological Hazards

19—Physical Hazards

20—Ergonomic Hazards

21—Employee Signature

Questions or concerns? Please
contact the Safety Department

Tami V., or Ashley L.

Safety Coordinator