Name: Date:
Task: Location:
# Hazard
Yes
No
1. Can I be caught on or in between anything?
2. Can I strain or over exert myself?
3. Can I come into contact with something that may harm me like heat, gas, fumes, electricity or stored energy (water, gas, oil or springs under pressure)?
4. Can something fall of strike me?
5. Is there anything about I can slip or trip on?
6. Can I fall or is there a chance of a fall from a
height?
7. Does any plant or equipment need to be isolated or tested for dead?
8. Is there a chance I could spill or pollute
something?
9. Is there a chance of equipment damage?
10. Do I need to communicate to my surrounding
workmates the risks associated with this task?
11. Can any nearby activities come into contact with me?
12. Do I need additional training or authorisation to complete the task?
If you answered Yes to any of the above, you must implement controls to eliminate or reduce the risk. Please complete the opposite page.

Please contact your supervisor if you cannot control the risks to an acceptable level and as low as reasonable achievable.
 # Hazard List the appropriate controls below
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