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GST Hazard Assessment Worksheet

Date Bldg Floor Area Job Number

Assessment by: ( ) Exterior ( ) Interior

Time:
Temp:
Wind:
Weather:
Work Surface:

I. Are MSDS sheets required? ( ) YES ( ) NO

II. Work to be performed:_______________________________________________________


_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

III. Identify the access and egress for employees, equipment and materials._______________
_________________________________________________________________________

IV. Identify the Equipment, tools, materials, concealed hazards and physical conditions in the area that may be
or can be hazardous to the employee(s).
( ) trip hazards ( ) JLG () temperature () holes in floor
( ) dust ( ) loose grating () mists () vapors
( ) falling objects ( ) forklifts () contaminants () ice
( ) slippery surfaces ( ) cranes () motors/shafts () spills (product)
( ) operating equipment ( ) pinching points ( ) sharp objects () other:________

V. Are other contractors or crews in the area? ( ) YES ( ) NO


Has contact been made with other contractors, discussing cross concerns? ( ) YES ( ) NO
What task are they performing?_________________________________________________

VI. Is flagging or barricades needed? ( ) YES ( ) NO


( ) ladders ( ) wire pulls ( ) electrical hazards ( ) testing in-progress sign
( ) Yellow tape ( ) Red tape ( ) Orange tape ( ) R/R blue flag
( ) Other:________________________

VII. What is the location of the nearest eyewash station:_____________________________________

VIII. PPE required for job: hard hast, safety glasses, safety toe work boots required at all times.
( ) goggles ( ) face shield ( ) insulated blankets ( ) Flash protection/Electrical
( ) leathers ( ) hearing protection ( ) foot protection ( ) temporary lights
( ) ventilation ( ) harness/lanyard ( ) dust mask ( ) safety cable
( ) grounding clamps ( ) safety monitor ( ) other:______________________
IX. Telephone (emergency <in plant phone> dial 9-911) nearest location:______________________

X. Are any work permits required? ( ) YES ( ) NO They must be obtained and posted.
( ) energized electrical equipment ( ) restricted area ( ) confined space
( ) burn permit ( ) other:________________________

XI. Lock-out / Tag-out? ( ) YES ( ) NO ( ) personal ( ) group


( ) lock-out ( ) tag-out
( ) lock/tag installed ( ) Meter check with voltage gloves ( ) Flash suit
( ) STORED ENERGY DRAINED GST employee in charge:___________________
( ) field controls ( ) PLC controls Plant personnel in charge:__________________
Verify ALL connected equipment and power surfaces deenergized and locked out!!!
Review all GST LOTO policies; confirm de energization by attempting to start at every conceivable location!!

Test Equipment Needed:


( ) Hipot ( ) Power Factor ( ) High Current ( ) Megger
( ) DLRO ( ) Baker ( ) Timing Test Set ( ) Other ___________

Will you energize test specimen? ( ) YES ( ) N0


If yes, hazard sign posted? ( ) YES ( ) NO
Second Person Needed? ( ) YES ( ) NO

XII. Are there any possible electrical hazards present? ( ) YES ( ) NO


( ) exposed live parts ( ) overhead lines ( ) induced voltage ( ) capacitors
( ) other:___________________________

XIII. Identify special tools or equipment needed and inspected:


( ) JLG / scissor lifts ( ) cranes ( ) scaffolding ( ) ladders
( ) other:__________________________
NOTE: ALL EQUIPMENT IS TO BE INSPECTED BEFORE AND AFTER USE!

XIV. Evacuation Routes and assembly areas:


Weather evacuation - _______________.
Catastrophic event – Primary-____________; Secondary-____________.
Non-catastrophic event – ____________.

XV. Perform and thorough and detailed walk through of the area including floors above and below that may be
affected. Discuss job to be done in detail, so all involved understand job duties and conditions reviewed
on this assessment sheet.

XVI. Note hazards or concerns of crew, discuss why the assessment is necessary.______________
________________________________________________________________________________
________________________________________________________________________________

________________________________ _________________________
GST Site-Lead Signature Date

________________________________ _________________________
ADM Personnel Signature Date