Professional Documents
Culture Documents
Hazard Assessment Survey Data Sheet Example: Town of Sunflower, Public Works Department
Hazard Assessment Survey Data Sheet Example: Town of Sunflower, Public Works Department
DATE OF EVALUATION
DEPARTMENT:
TELEPHONE:
ADDRESS/LOCATION:
POTENTIAL HAZARDS
Water Sampling/Acid Preservation:
Exposure to corrosive materials can cause several types of injuries, both acute and chronic. Primary injuries include
EVALUATION
To Date:
1 of 2 pages
CONTROLS
Existing Controls:
PPE:
Engineering:
Administrative:
2 of 2 pages
Surveyed By:
Reviewed By:
DATE OF EVALUATION
DEPARTMENT:
ADDRESS/LOCATION:
CHAINSAW
EVALUATION
CONTROLS
Existing:
Recommended: More safety instruction classes and annual refresher tool safety videos.
Reviewed By:
DATE OF EVALUATION
DEPARTMENT:
ADDRESS/LOCATION:
TRAFFIC / BARRICADING
EVALUATION
CONTROLS
Existing:
Recommended:
Surveyed By:
Reviewed By:
DATE OF EVALUATION
DEPARTMENT:
ADDRESS/LOCATION:
Actions are required by:
FIRE:
911
IF SAFE TO DO SO!
CONTROLS
Surveyed By:
Reviewed By:
DATE OF EVALUATION
DEPARTMENT:
DEPARTMENT:
TELEPHONE:
ADDRESS/LOCATION:
Actions are required by:
FIRE
CONTROLS
Surveyed By:
Reviewed By:
LOCATION:
DEPARTMENT:SECTION: