Professional Documents
Culture Documents
Supervisor: Job/Location: Date: Work To Be Done: Task Location
Supervisor: Job/Location: Date: Work To Be Done: Task Location
Supervisor: Job/Location: Date: Work To Be Done: Task Location
Once you have written all the hazards on the form, complete the third column, writing in the plans to eliminate the hazards. It is important that all hazards
have plans to eliminate them put in place. PPE, additional to the daily site requirements, must be listed. Grinder ratings and disc ratings must be listed.
New FLRA cards are to be completed whenever job locations and/or conditions change.
Tasks - Define task e.g. tools used Hazards - Be Specific Plans to Eliminate/Control Risk
All tools removed from task location? Yes N/A Flagging removed at end of job? Yes N/A
Task area cleaned up at end of job/shift? Yes N/A Permit signed off? Yes N/A
All members of task group must sign below prior to commencing work. Supervisor must review and sign-off prior to commencing task, or ASAP thereafter.
Print Name Initial Print Name Initial Print Name Supervisor (print & initial)