SITE SAFETY
ASSESSMENT

Jobsite Name:

Job #:

Address:

Year Built:

Loss Type:

Risk Classifications	Low (Green) Moderate (Yellow) High (Red) Please see guide to SSA "Risk Matrix"
Controls Required	Communicate to workers Eliminate the hazard Isolate / safe guard hazard Engineering controls Safe work procedures Personal Protective equip.
Instructions	Boxes should be filled in first by RISK CLASSIFICATION and then CONTROL NUMBER(S) Example: M 2 Complete new form as conditions change. Be alert to hazards not mentioned below. Please see guide to SSA.

Slip / Trip / Fall Hazard	Holes in floor Railing missing Working above 10' Work above 25' Ladders Scaffolding Poor lighting Site cluttered Loose step covering Ice / Snow Slippery surfaces Watch your step... Person Responsible: Date Corrected: Notes:

Physical Hazard	Structure unsafe Floor unsafe Ceiling unsafe Falling object Flying debris Sharp objects Ventilation Power tools Razor knife Forceful push / pulling Awkward lifting Heavy lifting Animal related Traffic Extreme heat / cold Take care when lifting... Person Responsible: Date Corrected: Notes:

Mechanical Hazard	Crushing / cutting Crushing / falling Falling objects Mobile Equipment Pressure lines Underground / excavation / wells Exposed moving parts Overhead Pilot lights Furnace backdraft Lock out / Tag out required? Person Responsible: Date Corrected: Notes:

Electrical Hazard	Exposed electrical panels Underground wires / conduits Energized equipment Exposed / bare wires Water / wet areas Overhead wires Concealed wires Lock out / Tag out required? Person Responsible: Date Corrected: Notes:

Chemical Hazard	Flammables Propane Natural gas / oil Cleaning products Smoke / fume Volatile organic compounds (VOCs) Hazardous gases Hazardous Atmosphere Unidentified chemicals Spontaneous combustion Safety Data Sheet Available? Person Responsible: Date Corrected: Notes:

Hazardous Materials	Asbestos Lead Mercury Silica Mould / Fungi Animal droppings Sewage Bodily fluids PCB's CFC's Radioactive materials Haz Mat Survey Conducted? Yes No Pending Posted Person Responsible: Date Corrected: Notes:

Confined Space Hazard

Confined Space Entry: If you answer "yes" to all 4 questions then a specific work and rescue procedure may be required. If you are unsure of the answer, contact your supervisor. Only suitably trained workers may enter a Confined Space. Yes No Does the space have limited or restricted means for entry or exit that may complicate emergency response service? Yes No Is the space enclosed or partially enclosed? Yes No Is the space large enough and configured in such a way that a person could enter to perform work? Yes No Is the space not designed or not intended for continuous human occupancy?

Check Box Of Required Personal Protective Equipment On This Site Are other site specific Notices / Permits / Plans required (including Working Alone)? Use notes at bottom   Yes No

Site Safety Assessment Meeting - Safety Hazard Discussion (ENTER NAMES OF ATTENDEES)

Form completed by:

Date:

Form reviewed by:

Date:

Purpose

• Identify hazards on a job site
• Assign risk level for each identified hazard
• Define controls for identified hazards
• Assign responsibility to implement controls
• Communicate the hazards to workers
• Document the process

Scope

• Completion of an SSA is required on any jobsite before work begins
• Updating the SSA is required as conditions change on the job site
• Completion of a new SSA is required at the start of a new shift

Worker Responsibility

• Complete an SSA before beginning work
• Involve coworkers in the SSA process
• Update the SSA as conditions change
• Post a copy of the SSA at the entrance to the work area

Supervisor Responsibility

• Ensure an SSA has been completed and posted
• Ensure the SSA has been completed properly
• Ensure any assigned actions to implement controls have been assigned and completed
• Communicate any updates to workers

Notes: