Production Department Activity Report Form
Date
-
Month
-
Day
Year
Date
Supervisor Name
First Name
Last Name
Name for all people on the job
Task
Describe the task to be performed.
Task Location
Identify all hazards that exist.
Suspended loads or overhead hazards
Working at heights > 4'
Motion/Lifting/Lowering/Twisting
Chemicals
Housekeeping or job site conditions
Hand or power tools/equipment
Water/temperature, heat stress, cold stress
Stored energy (electrical, air, hydraulic, pnuematic)
Confined spaces or other potential atmospheric hazards
Animals, insects, poisonous plants
Walking or working surfacs (clear path, uneven terrain, etc)
Underground utility
Enviornmental hazards
Other
How can you mitigate the hazards?
PPE
Eyes on path
Ladder inspection
3 points of contact
SDS sheet
Harness inspection
Slign/hoise inspection
Air monitor
Establish safe work zone
SOPs
Mark out
Other
Are there any Permits required?
Confined Space Permit
Lock/Out Tag Out Permit
Hot Work Permit
Excavation Permit
Other
Submit
Should be Empty: