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Town of Canmore Pre-Work Hazard Assessment Form
Name(s)
*
*
Department
Engineering
GIS & Mapping
Hazard Management
Infrastructure
Parking Management
Transit
Data & Time
*
*
Location
*
*
Assigned Prime Contractor
*
*
Contractor must be assigned in writing and identified on this form for all active construction sites
*
Contractor must be assigned in writing and identified on this form for all active construction sites
First visit to site
Contractor must be assigned in writing and identified on this form for all active construction sites
Return visit to site
Slip Trip or Fall
*
Hazard Rating – Please Select One(1 = least hazardous; 5 = most hazardous)
Slip Trip or Fall
1
Slip Trip or Fall
2
Slip Trip or Fall
3
Slip Trip or Fall
4
Slip Trip or Fall
5
Slip Trip or Fall Hazard Type
*
(ex. power lines, steep slope, etc.)
Overhead Hazard
*
Hazard Rating – Please Select One(1 = least hazardous; 5 = most hazardous)
Overhead Hazard
1
Overhead Hazard
2
Overhead Hazard
3
Overhead Hazard
4
Overhead Hazard
5
Overhead Hazard Type
*
(ex. power lines, steep slope, etc.)
Environmental (Weather)
*
Hazard Rating – Please Select One(1 = least hazardous; 5 = most hazardous)
Environmental (Weather)
1
Environmental (Weather)
2
Environmental (Weather)
3
Environmental (Weather)
4
Environmental (Weather)
5
Environmental Hazard Type
*
(ex. power lines, steep slope, etc.)
Mechanical (Equipment)
*
Hazard Rating – Please Select One(1 = least hazardous; 5 = most hazardous)
Mechanical (Equipment)
1
Mechanical (Equipment)
2
Mechanical (Equipment)
3
Mechanical (Equipment)
4
Mechanical (Equipment)
5
Mechanical Hazard Type
*
(ex. power lines, steep slope, etc.)
Vehicular
*
Hazard Rating – Please Select One(1 = least hazardous; 5 = most hazardous)
Vehicular
1
Vehicular
2
Vehicular
3
Vehicular
4
Vehicular
5
Vehicular Hazard Type
*
(ex. power lines, steep slope, etc.)
Overall Risk Rating
*
Overall Risk Rating
Low
Overall Risk Rating
Medium
Overall Risk Rating
High
PPE Required on Site
Control Checklist
Muster Point Location (if applicable)
*
Additional Notes
*
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