Pre-job safety assessment and near miss report 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 * 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+ 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 reCAPTCHA Submit Δ
