Field Level Hazard Assessment — Information
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PPE / Safety Requirements — check all that apply
Potential Hazards — check all that apply
Work Scope & Risk Assessment
Severity
Probability
Minor Injury
or Damage
or Damage
Personnel Sent to Hospital /
Moderate Damage
Moderate Damage
Death or Permanent Disability /
Serious Damage
Serious Damage
1
2
3
Unlikely to Occur1
2
3
4
Could Occur at Some Time2
3
4
5
Likely to Occur Soon3
4
5
6
| Scope of Work | Hazard # | Severity (Pre) |
Probability (Pre) |
Risk Rank (Pre) |
Severity (Post) |
Probability (Post) |
Risk Rank (Post) |
|---|
Pre-Use Inspections — check when completed (if applicable)
Signatures