Online SSA Form

SSA Form

SITE SAFETY
ASSESSMENT

SITE SAFETY
ASSESSMENT

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Job Name:

Job #:

Address:

Year Built:

Loss Type:

Task Type:

Critical Task: YES       NO

Are other site-specific Notices, Permits, Plans required (including Working Alone)? If yes, they will be listed in the notes on the second page of this form.
YES    NO

INSTRUCTIONS: For detailed instructions on filling out this form, see the SSA Guide. You will need to complete a new form as conditions change. Always be alert to potential hazards that may arise and not mentioned below. Fill out the boxes below by identifying RISK CLASSIFICATION and then CONTROL NUMBER. Ex. L. 2

RISK CLASSIFICATIONS: See page 2 for the risk matrix
L   LOW   M   Moderate    H   High

Choose the CONTROLS REQUIRED for this job or task to reduce hazard
1   Elimination   2   Isolate/Safeguard   3   Engineering   4   Safe Job Procedures   5   PPE

Check all required Personal Protective Equipment on this Site/Task (as required) 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 Ask for help when needed! Person Responsible: Date Corrected: Notes: Mechanical Hazard Crushing / cutting Crushing / falling Falling objects Mobile Equipment Pressure lines Underground Exposed moving parts Overhead Excavations / Wells Pilot lights Furnace backdraft Lockout / Tagout 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 Lockout / Tagout required? Person Responsible: Date Corrected: Notes: Chemical Hazard Flammables Propane Natural gas / oil Smoke / Fumes Cleaning products Hazardous Atmosphere Hazardous gases Unidentified chemicals Spontaneous combustion Volatile organic compounds (VOCs) Safety Data Sheet Available? Yes No 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 If you answer "yes" to all 4 questions, then a specific work and rescue procedures may be required. Refer to OHSR 9.1 more information. ONLY TRAINED & QUALIFIED WORKERS MAY ENTER A CONFINED SPACE. If you are unsure, contact your supervisor right away! 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?

COMMUNICATION TO WORKERS/SAFETY HAZARD DISCUSSION (PRINT AND INITIAL NAMES OF ATTENDEES) add to back if required

Instructions

Steps to completing the Site Safety Assessment:

1. Identify Hazards on a job site
2. Assign risk level for each identified hazard
3. Define controls for identified hazards
4. Assign responsibility to implement controls
5. Determine the required personal protective equipment PPE
6. Communicate the hazards to workers
7. Document the process

Requirements

• 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
• Ensure all required emergency equipment is available on the jobsite

Supervisor Responsibility

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

Critical Task:

• If you check yes, to a critical task; develop and follow the Safe Work / Job Procedures for that task.
• Involve coworkers in the SSA process
• Update the SSA as conditions change
• Ensure training and supervision is provided.