Field Level Hazard Assessment

11220 — 143 Street, Edmonton AB T5M 1V5 · Ph 780-669-9283

Our Job # Date

Weekday Sun Mon Tue Wed Thu Fri Sat

Customer

Job Type Signal Check Installation Service Call Tower Rooftop Other

Job Location / Address

Leadhand / Supervisor Emergency Contact #

Workers Present

Hazard Hit List

Check anything that applies to this job. Anything checked must have a plan.

Job Hazard Assessment

General Tasks / Special Considerations KMs Traveled Filled out by (your name)

JHA — Hazard Hit List

Client / Customer Date

Job Location / Address

Leadhand / Supervisor

Check anything that applies on this job. Anything checked must have a plan.

Incident Reporting (Near or Definite Hit)

1) What happened? 2) Who was present? 3) Was anyone hurt? 4) Were safe work practices followed? 5) What could have been done better?

Rescue / Emergency Plan

Emergency contact numbers Exact location for emergency response How will you perform the rescue? How long for external rescuers to arrive? Filled out by

Incident Report

Client / Customer Date

Job Location / Address

Leadhand / Supervisor

Incident Reporting (Near or Definite Hit)

1) What happened? 2) Who was present? 3) Was anyone hurt? 4) Were safe work practices followed? 5) What could have been done better?

Rescue / Emergency Plan

Emergency contact numbers Exact location for emergency response How will you perform the rescue? How long for external rescuers to arrive? Filled out by

Fall Protection Plan

Work Site Date

Location

Supervisor

Scope of Work Install / Swap Antenna Tower Maintenance Running Lines Stacking

Scope detail

Identified Fall Hazards Tower Climbing Tower Transitioning Working on Tower Ladders Elevated Platform Open Trench / Excavation Trip Slip Rooftop Stairs

Hazard detail

Fall Protection System Used Barrel Slider Cable Slider T Slider Double Lanyard 2m from edge Rope Grab Rope Slider Guardrails Travel Restraint Fall Arrest

Fall protection detail

Anchor Point

Anchor description Rated capacity

Rescue Plan

Rescue method Man Basket Ladder Truck High Angle Rescue Self Rescue Assisted Self Rescue

Rescue plan detail

First Aider on Site Emergency # (911 if available)

Crew Sign-off

Filled out by

Past Submissions

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