PRE-JOB HES CHECKLIST
Date: Section/Department: Safety Officer: Location:
Job Description:
Sequence of Basic Job Steps:
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
Hazard Assessment: Consider all possibilities listed in the boxes below and check all that apply to the specific job
listed.
PERMITS REQUIRED AND REQUIREMENTS: HAZARDS:(PERSONAL INJURY) HAZARDS: ( ENVIRONMENT)
Cold Work Housekeeping Flying Particles Electrical Shock
Hot Work Slip/Trip Falling Particle Heat Stress
Confined Space Entry Falls Inhalation Lightning
Vehicle Entry Pinch Points Cave in Noise Level
Excavation Cuts Scaffolds Tagged Congested Area
Lockout, Tag-out and Try Sprains/Strains Ladders Inspected Slippery/Slick
Drained, Purged, Cleaned Falling Objects Falling Objects Thermal
Others: _________________ Others:__________ Others:__________
_____________________ ________________ ________________
HAZARDS:(CHEMICAL) PERSONAL PROTECTIVE EQUIPMENT
Acid Gloves (Leather, Rubber, Nitrile, Cut & Heat Resistant, Cotton, etc.)
Caustic Foot Protection (Leather/Rubber Steel Toe Boots)
Thermal Burn Full Body Harness, Fall Arrest
Reactivity Protective Clothing (Chemical Suit, Tyvek, Weldor’s Apron, Proximity Suit)
Flammability Eye & Face Protection (Welding Mask, Face Shield, Goggles)
Ingestion Respiratory Protection (SAR, SCBA, Dust Mask, Half/Full Face (Cartridge)
Volatile Hearing Protection
Others: _________________ Head Protection (Hard Hat, Bump Cap)
_____________________ Others as required by the Job: ______________________________________
ENVIRONMENTAL/POLLUTION POTENTIAL RIGGING: OVERHEAD WORKS
Spill/Leak Required Barricades
Air Rigging Tools Inspected Warning Signs
Waterway Pre-Lift Meeting Perimeters Defined
Others: _________________ Crane Inspected Others: _____________
_____________________ Others: _____________
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PRE-JOB HES CHECKLIST
LIST OTHER HAZARDS (not already identified):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
HAZARD ELIMINATION OR CONTROL:
Personal Protective
Personal Equipment,
Protective SafeWork
Equipment, Working Practices
& Safety and Procedures
Procedures
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
ARE ALL PERSONNEL TRAINED, HAVE ADEQUATE LEVEL OF EXPERIENCE AND QUALIFIED ON THE TOOLS AND
EQUIPMENT THEY PLAN ON USING TO PERFORM THE TASK? YES NO
LIST ANY SIGNIFICANT WORK BEING DONE IN THE AREA THAT WILL BE WORKED ON THAT COULD POSSIBLY CHANGED
THE JOB SEQUENCE OR CAUSE THE NORMAL ROUTINE OF WORK TO BE INTERRUPTED (Example: overhead lifts,
confined space entry, other contractors works, etc.).
I ACKNOWLEDGE THAT THE JOB I AM ABOUT TO PEFORM HAS BEEN EXPLAINED TO ME IN DETAIL AND THE SEQUENCE
OF STEPS TO FOLLOW INCLUDING HAZARDS CONTROL MEASURES.
NAME SIGNATURE DATE
Supervisors Review During Shift: By: ____________________ Date/Shift: ______________
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