Supervisor: Date: Task Location:

Job/Location: Work to be Done:

On the bottom of this page, list all hazards that may be present during the task(s). Here is a list of possible hazards to help you identify
them. Put a mark beside all that apply, and list them on the bottom of this page.
Environmental Hazards Ergonomic Hazards Rigging Hazards
Work area clean Awkward body position Slings in good condition/inspected
Material storage identified Lift too heavy/awkward Signal vest
Dust / Mist / Fumes Walk area not clear/level Load weight identified
Noise in area Repetitive motion Lifting overhead/live equipment
Extreme temperatures Prolonged twisting/bending Overhead power line
Spill potential Parts of body in line of fire Equipment inspected
Excavation permit required Work Environment Hazards Barricades and signs in place
Other workers in area Slips or trips possible Holes covered and identified
Weather conditions Limited access/egress Personal Limitations
Working at Heights Foreign bodies in eyes Procedure not available for task
Hardness required/Tie-off Exposure to electrical
identified hazards No training for tools to be used
Others working above/below Lock-out procedure First time performing this task
Falls from heights Lighting levels too low Distractions in area
Objects falling from work area Exposure to noise Confusing instructions
Elevated work platform hazards Exposure to heat/cold Equipment Hazards
Elevated platform ground cond. Exposure to steam Operating power equipment
Scaffold inspected and tagged Exposure to dust Working with grinders
Ladder tied off Exposure to chemicals Circular saws
Personnel baskets inspected & Position of hands - pitch
Chain saws
approved points
Hoisting tools (come-a-longs)
Emergency Explosive actuated tools
inspected
Emergency meeting point
Hoisting tools sized for job Cutting torches
identified
Evacuation routes identified Hand tools (knives, saws)
Evacuation location identified Power trawlers

Once you have written all the hazards on the form, complete the third column, writing in the plans to eliminate the hazards. It is important that all hazards
have plans to eliminate them put in place. PPE, additional to the daily site requirements, must be listed. Grinder ratings and disc ratings must be listed.
New FLRA cards are to be completed whenever job locations and/or conditions change.

Tasks - Define task e.g. tools used Hazards - Be Specific Plans to Eliminate/Control Risk

All tools removed from task location? Yes N/A Flagging removed at end of job? Yes N/A
Task area cleaned up at end of job/shift? Yes N/A Permit signed off? Yes N/A
All members of task group must sign below prior to commencing work. Supervisor must review and sign-off prior to commencing task, or ASAP thereafter.

Print Name Initial Print Name Initial Print Name Supervisor (print & initial)