Field Level Risk Assessment (FLRA)

IMPACT HSE INC..
Site-Specific Hazard Assessment
FIELD LEVEL RISK ASSESSMENT (FLRA)
Client*
Location*
Date*
YearMonthDay
DateHourMinutes
Supervisor*
Name
Signature*
Clear
Daily Task(s)*
Hazard(s)*
Hot WorkSlips/Trips/FallsExposure to NoiseWorking at HeightsWorking in Tight SpacesHot SurfacesH2S PresentConfined Space EntryLimited AccessPinch PointsOperating Power EquipmentAwkward Body PositionsMetal Grinding / SparksFirst Time Performing TaskCorroded MetalsChemical ExposureManmade MineralsNORMSElectrical HazardsCritical LiftWeather - HotWeather - ColdAirborne ContaminantsFlammable ProductsWorking AloneWildlifeSurrounding TrafficSurrounding WorkersOther
Control Measure(s)*
Safety GlassesDaily Work PermitFull Face ShieldGas MonitorCareful DrivingHearing ProtectionFR CoverallsIdentify Tie-OffsAir CirculationReview MSDS/SDSSupplied AirHousekeepingFire ExtinguisherBe Aware / AlertConfined Space PermitRespiratorsLock Out / Tag OutUse Care / CautionStay ClearBear KitBarricades / SignsReview Rescue PlanOther
Additional Hazards and Controls
Permit Required?
Permit Type
General Work PermitConfined Space EntryHot WorkCold WorkOther
Permit Number
Muster points ID'd?
Gas Monitor Bumped?
Initial Gas Monitoring Required?
Initial Air Quality Readings
Additional Crew Members
Worker 1
Name
Worker 2
Name
Worker 3
Name
Worker 4
Name
Signature 1
Clear
Signature 2
Clear
Signature 3
Clear
Signature 4
Clear
Should be Empty: