Restoration Worksite Safety Assessment Form
Complete this form to record the site details, identify restoration worksite hazards, and document overall safety readiness before work proceeds.
Worksite Overview
Project/Site Name
*
Worksite Address / Location
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name
*
Safety Assessment Details
Site Condition Assessment
*
Rows
Low Risk
Moderate Risk
High Risk
Structural instability
1
2
3
Water damage
4
5
6
Mold exposure
7
8
9
Electrical hazards
10
11
12
Slip/trip risks
13
14
15
Dust/debris
16
17
18
Confined or restricted access
19
20
21
Observed hazards and required corrective actions
*
Overall site safety condition
*
1
2
3
4
5
Immediate work restrictions needed?
*
No
Yes
Readiness and Follow-Up
Overall Readiness Rating
*
Ready to Proceed
Proceed with Controls
Delay Work Until Hazards Are Addressed
Follow-Up Notes
Submit Assessment
Should be Empty: