Hazard Assessment Form
Assessment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Company Name
Company Phone Number
-
Area Code
Phone Number
Company Email
example@example.com
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Types of Hazards present in the job
Rows
Present
Absent
Remarks
Debris
1
2
Chemical exposure
3
4
Electrical shock
5
6
UV radiation
7
8
Temperature
9
10
Gases or vapors
11
12
Fumes
13
14
Lack of oxygen
15
16
Loud noises
17
18
Cuts or abrasion
19
20
Puncture
21
22
Slippery/Wet Surfaces
23
24
What are the risk factors that can be associated with the listed hazard above?
Who are the people/employee who are at risk of being affected by the hazard?
What has already been done to control the hazard?
Personal Protective Equipment (PPE) required for the job
Rows
Yes
No
Remarks
Eye protection
25
26
Face protection
27
28
Respiratory protection
29
30
Head protection
31
32
Foot Protection
33
34
Ventilation
35
36
Occupational noise exposure
37
38
Hazardous waste
39
40
Electrical protective equipment
41
42
Hand protection
43
44
Personal fall protection systems
45
46
Assessment Conducted by
First Name
Last Name
Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Print Form
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