T.R.A.C.K.
Risk Assessment
Employees Involved in TRACK
*
Matt Kramer
Tony Swoboda
Scott Asbra
Kenny Sherer
Tony Krutina
Max Blair
Thomas Inzauro
Jalen Samson
Jeff Etter
Greg Ahlers
Tyson Whitney
Scott Plambeck
Bryan Koeliker
Matt Abels
Mike Heger
Robert Brockhaus
Other
Supervisor
Date
*
-
Month
-
Day
Year
Date
Operating Company
Ready Mixed
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location
*
36th and L
7th and Seward
Bellevue
CB
Elkhorn
Gretna
Millard
Fremont
Blair
Mo Valley
Bunge
Springfield
RMC Shop
Other
Location (only if other is selected)
Task To be Performed
*
*
*
1. Vehicles/ Transportation..............
2. Gravity.................
3. Biological............
4. Climate/ Natural Events......................
5. Electrical/ Magnetic....................
6. Ergonomics............................
7. Mechanical......................
8. Natural environment/ Ecosystem.............
9. Personal/ Behavioral...….
10. Pressure..................
11. Radiation.................
12. Sound/Vibration.................
13. Substances.................
14. Thermal/ Fire...............
15. Work Environment..................
Other
Vehicle Impact on Person
1
Vehicle Collision or Rollover
2
Fall from Heights
3
Falling Objects
4
Lifting Operations
5
Entanglement and Crushing
6
Contact with Electricity
7
Uncontrolled Release of Energy
8
Confined Space
9
Slope Failure
10
Exposure to Thermal Extremes
11
Unplanned Initiation of Explosives
12
Risk of the hazard: How will I be injured from the hazards I have recognized?
*
Have I recognized a hand/ finger risk and implemented the appropriate controls?
*
Yes
No
All risk recognized must be controlled. Please list how you are going to control the hazards that you have listed.
*
Have I informed others who may be affected by my work?
*
Have I informed others who may be affected by my work?
*
Yes
NO
Do I have the right tools for the job and are they in safe condition?
*
Do I have the right tools for the job and are they in safe condition?
*
YES
NO
Am I fit for duty?
*
Am I fit for duty?
*
YES
NO
I am responsible for my safety. I will stop the job if it is unsafe.
The reason I worked safe today
*
Signature
*
Submit
Should be Empty: