Number: C-FM10.

0-0059

MAINTENANCE WORK ORDER RISK ASSESSMENT FORM Revision: 3

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Unit # WO # Assigned to
Hours #1 km/miles FP Stroke Count
Hours #2 CVIP/DOT Expiry Hrs to Service
Pre Work Checklist Post Work Checklist
Task Completed N/A Initials Dates Task Completed N/A Initials Dates
Drive Unit Service Sticker

Guide/Walk Around Remove LOTO

Install chocks, LOTO Guide/ Walk Around

Oxidizer, Methanol, Test Repairs

Other
Hydrocarbon/NORMS Sign DVIR

Job Safety Assessment

If Residual Risk Potential is deemed to be a 3 or 4, a supervisor needs to sign off the Task before starting work
Task Hazards Controls Residual Sup.
Risk Initials

Print Name Signature Date

Paper Print Name Signature Date

work
Complete

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