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FLHA (Field Level Hazard Assessment) 

Sample Form


Changes in Tasks?

If yes, what new task(s) are you performing? Please select below areas identified with new task(s)

Environmental Hazards

2. Material Storage Identfied
1. Work Area Clean
3. Dust/Mist/Fumes
4. Noise In Area
5. Extreme Temperatures
7. Waste Properly Managed
8. Excavaton Permit Required
9. Other Workers In Area
11. MSDS Reviewed
6. Spill Potential
10. Weather Conditions
17. Hands Not In Line of Sight
16. Lift Too Heavy/Awkward to Lift
15. Working in a Tight Area
14. Prologed twisting/Repetitive/Bending Motion
13. Over Extension
12. Awkward Body Position

Ergonomic Hazards

18. Working Above Your Head

Access/Egress Hazards

19. Aerial Lift/Man Basket (inspected & tagged)
21. Ladders (tied off)
20. Scaffold (inspected & tagged)
22. Slips/Trips
23. Hoisting (Tools & Equipment)
24. Evaculation (Alarms, Routes, Muster Pnts, Ph Numbers
25. Confined/Restricted Space Entry Permit Required

Overhead Hazards

26. Barricades & Signs In Place
28. Harness/Lanyard Insected
27. Hole Coverings Identified
31. Power Lines
30. Falling Objects
29. 100% Tie-off with Harness/Anchor Ponits Identified
32. Hoisting or Moving Loads Overhead
38. Critical Lift Permit Required
37. Others Working Above/Below
36. Equipment Inspected
35. Tools/Slings Inspected
34. Proper Tools Used
33. Lift Study Required

Rigging & Hoisting Hazards

Electrical Hazards

39. GFI Test
40. Lighting Levels Too Low
41. Working On/Near Energized Equipment
42. Electrical Cords/Tools Condition
43. Fire Extinguisher
44. Hot Work/Electrical Permit Required
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Personal Limitations/Hazards

45. Is Procedure Available For Task
47. No Training for Task or Tools to be Used
46. Confusing Instructions
48. First Time Performing the Task
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Severity (S)

Probability (P)

  1. Imminent Danger - causing deaths, widespread occupational illness, loss of facilities.

  2. Serious - severe injury/illness, property and/or equipment damage.

  3. Minor - non-serious injury, illness or damage

  4. Not Applicable

  1. Probable - likely to occur immediate or soon.

  2. Reasonably Probable - likely to occur eventually.

  3. Remote - could occur at some point.

  4. Extremely Remote - unlikely to occur.

Tasks & Risk Assessments


PPE To Be Used

Crew Information

Check if yes

Check if agree

By entering your name, qualification and checking the Acknowledge box, you are agreeing to all risks, hazards and controls stated on this FLHA.

End of Shift

Check if yes for all end of shift items.

Hazards Remaining
Any Injuries/Incidents
Option: Add an upload link to your company's health & safety policy here.

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