Date

Procore Employee

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Site Lead

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Procore Location

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Procore Company

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Hazard Identification

Are the following HAZARDS present on your Job site?

Slips Falls Trips

Slips Falls Trips NoSlips Falls Trips Yes

Pinch Point

Pinch Point NoPinch Point Yes

Struck By Hazards

Struck By Hazards NoStruck By Hazards Yes

General Electrical Hazards

General Electrical Hazards NoGeneral Electrical Hazards Yes

Shock Arc Flash

Shock Arc Flash NoShock Arc Flash Yes

Cuts

Cuts NoCuts Yes

Elevated Work

Elevated Work NoElevated Work Yes

Hazardous Chemicals

Hazardous Chemicals NoHazardous Chemicals Yes

Lifting

Lifting NoLifting Yes

Noise

Noise NoNoise Yes

Hazards Details

PPE

Do you have the following list of PPE available to you for use?

Hard Hat

Hard Hat NoHard Hat Yes

Gloves

Gloves NoGloves Yes

Safety Glasses

Safety Glasses NoSafety Glasses Yes

Face Mask

Face Mask NoFace Mask Yes

Ear Plugs

Ear Plugs NoEar Plugs Yes

Fall Protection

Are you using any Fall Protection equipment today?

Fall Protection Equipment

Fall Protection Equipment NoFall Protection Equipment Yes

Tool Inspection

Powers Tools

Powers Tools NoPowers Tools Yes

Using Ladder

Using Ladder NoUsing Ladder Yes

Type Of Ladder

Have you completed the following safety precaution checks?

General Ladder Safety

Altered Ladder

Altered Ladder NoAltered Ladder Yes

Ladder Integrity Due To Weather

Ladder Integrity Due To Weather NoLadder Integrity Due To Weather Yes

House Keeping Of Ladder

House Keeping Of Ladder NoHouse Keeping Of Ladder Yes

Ladder Rungs Clean Of Impurities

Ladder Rungs Clean Of Impurities NoLadder Rungs Clean Of Impurities Yes

Feet Positioned Middle Of Rung

Feet Positioned Middle Of Rung NoFeet Positioned Middle Of Rung Yes

Precaution Taken Near Live Power

Precaution Taken Near Live Power NoPrecaution Taken Near Live Power Yes

Three Points Of Contact

Three Points Of Contact NoThree Points Of Contact Yes

Overhead Obstructions Eliminated

Overhead Obstructions Eliminated NoOverhead Obstructions Eliminated Yes

Ladder Set On Stable Surface

Ladder Set On Stable Surface NoLadder Set On Stable Surface Yes

Facing Ladder

Facing Ladder NoFacing Ladder Yes

Step Ladder Inspection

Step Bent Cracked Loose Missing Steps

Step Bent Cracked Loose Missing Steps NoStep Bent Cracked Loose Missing Steps Yes

Step Missing Unreadable Labels

Step Missing Unreadable Labels NoStep Missing Unreadable Labels Yes

Step Bent Broken Cracked Loose Top

Step Bent Broken Cracked Loose Top NoStep Bent Broken Cracked Loose Top Yes

Step Bent Broken Loose Spreader

Step Bent Broken Loose Spreader NoStep Bent Broken Loose Spreader Yes

Step Corrosion Loose Rust General

Step Corrosion Loose Rust General NoStep Corrosion Loose Rust General Yes

Step Brace Shoe Rivet Good Condition

Step Brace Shoe Rivet Good Condition NoStep Brace Shoe Rivet Good Condition Yes

Step Ladder Details

EXTENSION LADDER

Extension Rungs Bent Cracked Loose Missing

Extension Rungs Bent Cracked Loose Missing NoExtension Rungs Bent Cracked Loose Missing Yes

Extension Rails Bent Cracked Frayed Split

Extension Rails Bent Cracked Frayed Split NoExtension Rails Bent Cracked Frayed Split Yes

Extension Labels Missing Unreadable

Extension Labels Missing Unreadable NoExtension Labels Missing Unreadable Yes

Extension Hardware Broken Loose Missing

Extension Hardware Broken Loose Missing NoExtension Hardware Broken Loose Missing Yes

Extension Shoes Broken Missing Worn

Extension Shoes Broken Missing Worn NoExtension Shoes Broken Missing Worn Yes

Extension Pulley Bent Broken Loose

Extension Pulley Bent Broken Loose NoExtension Pulley Bent Broken Loose Yes

Extension Bracing Rivets Good Condition

Extension Bracing Rivets Good Condition NoExtension Bracing Rivets Good Condition Yes

Extension General Corrosion Loose Rust

Extension General Corrosion Loose Rust NoExtension General Corrosion Loose Rust Yes

Extension Above Landing

Extension Above Landing NoExtension Above Landing Yes

Extension Tie Off

Extension Tie Off NoExtension Tie Off Yes

Extension Position

Extension Position NoExtension Position Yes

Extension Reach

Extension Reach NoExtension Reach Yes

Extension Height

Extension Height NoExtension Height Yes

Additional Questions

Additional Safety Measures

Warm And Stretch

Warm And Stretch NoWarm And Stretch Yes

Lockout Tagout Necessary

Lockout Tagout Necessary NoLockout Tagout Necessary Yes

Energized Work Permit

Energized Work Permit NoEnergized Work Permit Yes

Emergency Plan

Emergency Plan NoEmergency Plan Yes

Emergency Plan Reviewed

Emergency Plan Reviewed NoEmergency Plan Reviewed Yes

Fire Extinguisher Located

Fire Extinguisher Located NoFire Extinguisher Located Yes

First Aid Kit

First Aid Kit NoFirst Aid Kit Yes

Additional Safety Measures Notes

Additional Safety Measures Photos

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Company name

Job Hazard Analysis Form

Hazard Identification

Are the following HAZARDS present on your Job site?

PPE

Do you have the following list of PPE available to you for use?

Fall Protection

Are you using any Fall Protection equipment today?

Tool Inspection

Tool Inspection

Have you completed the following safety precaution checks?

General Ladder Safety

Step Ladder Inspection

EXTENSION LADDER

Additional Questions

Additional Safety Measures