IMPACT HSE INC..
Site-Specific Hazard Assessment
FIELD LEVEL RISK ASSESSMENT (FLRA)
Client
*
Location
*
Date
*
 -
Year
 -
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Hour Minutes
Supervisor
*
Name
Signature
*
Daily Task(s)
*
Hazard(s)
*
Hot Work
Slips/Trips/Falls
Exposure to Noise
Working at Heights
Working in Tight Spaces
Hot Surfaces
H2S Present
Confined Space Entry
Limited Access
Pinch Points
Operating Power Equipment
Awkward Body Positions
Metal Grinding / Sparks
First Time Performing Task
Corroded Metals
Chemical Exposure
Manmade Minerals
NORMS
Electrical Hazards
Critical Lift
Weather - Hot
Weather - Cold
Airborne Contaminants
Flammable Products
Working Alone
Wildlife
Surrounding Traffic
Surrounding Workers
Other
Control Measure(s)
*
Safety Glasses
Daily Work Permit
Full Face Shield
Gas Monitor
Careful Driving
Hearing Protection
FR Coveralls
Identify Tie-Offs
Air Circulation
Review MSDS/SDS
Supplied Air
Housekeeping
Fire Extinguisher
Be Aware / Alert
Confined Space Permit
Respirators
Lock Out / Tag Out
Use Care / Caution
Stay Clear
Bear Kit
Barricades / Signs
Review Rescue Plan
Other
Additional Hazards and Controls
Permit Required?
Permit Type
General Work Permit
Confined Space Entry
Hot Work
Cold Work
Other
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
Signature 2
Signature 3
Signature 4
Submit
Should be Empty: