Simple Field Level Risk Assessment (FLRA)

FIELD LEVEL RISK ASSESSMENT (FLRA)
Site-Specific Hazard Assessment
Date*
YearMonthDay
DateHourMinutes
Supervisor Email*
example@example.com
Permit Required?
Permit Reviewed?
Permit Number
Task Location*
Client*
Company Performing Work*
Emergency Assembly Point*
Emergency Contact Number*
Daily Task(s)*
Insepct the work area for common hazards and check them off on the list. Any hazards identified must have controls put in place.
Hazard(s)*
EnvioronmentalErgonomicAccess/ EgressEnergyEquipment/ CranesOverheadFallsPersonal LimitationsHealthHazardous MaterialsOther
Task Analysis
Task Step Hazards Controls
1
2
3
4
5
6
Safety Equipment and PPE Required*
Basic PPE (Steel toed- boots, safety eyewear, hardhatWork GlovesCut-resistant glovesFall ProtectionFull Face ShieldGas MonitorHearing ProtectionFR CoverallsSupplied AirFire ExtinguisherRespiratorsPersonal LockBear KitOther
Additional Hazards and Controls
Additional Crew Members
Worker 1
Name
Signature 1
Clear
Worker 2
Name
Signature 2
Clear
Worker 3
Name
Signature 3
Clear
Worker 4
Name
Signature 4
Clear
End of Shift Supervisor Check*
Permits closed out?Area cleaned up?No hazards remainingNo injuries or incidents
Supervisor*
Name
Signature*
Clear
Should be Empty:

FIELD LEVEL RISK ASSESSMENT (FLRA)