Pre-job safety assessment and near miss report Hazard matrix with controls can be found here: Risk Matrix Pre-job hazard assessement Assessment Type * Pre-job safety survey Hazard ID Near Miss Date * Time * 121234567891011 : 0030 AMPM Location / Task * Name * List hazards and calculate risk using risk matrix or describe event * Visual Text (HTML) Examples (replace with your own): Driving to site - Bad weather - Severity 4/Likelihood 2/Risk 8 Driving to site - Wildlife - 4/1/4 Washing samples - Chemical exposure - 2/1/2 Hazard breakdown for Risk Activities | Severity Scale: 4 Serious injury or death possible 3 Possible hospitalization 2 First aid or ongoing therapy require 1 Minor acute or chronic injury that does not require intervention | Frequency: 4 Likely to happen without extreme precautions 3 Likely to happen occasionally under normal circumstances 2 May happen once every few years 1 Not likely to happen | Risk = Severety X Frequency Low risk – 1 to 3 Moderate risk – 4 to 8 High risk – 9 to 12 Unacceptable risk – 12+ Hazard controls * Visual Text (HTML) Examples (replace with your own) Driving to site (bad weather): Engineering controls; well maintained vehicle, functional headlights, proper tires: Admin controls; only drive during daylight hours, fill out journey form, take appropriate rest stops: PPE; airbags, seatbelt. Driving to site (wildlife): Engineering controls; well maintained vehicle, functional headlights: Admin controls; only drive during daylight hours, fill out journey form, take appropriate rest stops: PPE; airbags, seatbelt. Washing Samples: Engineering controls; fume hood, sample dryer: Admin controls; wash only when needed, use low-risk cleaning supplies when possible: PPE; mask, gloves, safety glasses and long-sleeve shirt. For each of the identified hazards, document which controls are in place to mitigate risk. Engineering controls are procedures or equipment that reduces or eliminates risk such as guardrails. Administrative controls are policies that limit the need to engage in hazardous activity and PPE is there in the event engineering and administrative controls are insufficient. PPE Required No Yes PPE Details Gloves No Yes Glove Inspection Fail Pass Safety Glasses No Yes Safety Glass Inspection Fail Pass Face Shield No Yes Face Shield Inspection Fail Pass Hearing protection No Yes Hearing PPE Inspection Fail Pass Fireproof clothing No Yes Fireproof Clothing Inspection Fail Pass Steel toe boots No Yes Boot Inspection Fail Pass Other Email Enter Email if you wish to receive a copy. Captcha If you are human, leave this field blank. Submit Δ