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Safety Task Assessment Form

This document outlines a safety task assessment (STA) for identifying hazards associated with a particular job task. The STA includes sections to describe the job, identify required personal protective equipment, inspect for hazards in the work area, specify emergency procedures, list specialized operations, and document a sequence of job steps along with associated hazards and recommended safety actions. A supervisor must sign off on the STA after reviewing it with crew members. Crew members then sign to acknowledge they understand the instructions and will comply with the assigned safety precautions.

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Rajkumsr V
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4K views2 pages

Safety Task Assessment Form

This document outlines a safety task assessment (STA) for identifying hazards associated with a particular job task. The STA includes sections to describe the job, identify required personal protective equipment, inspect for hazards in the work area, specify emergency procedures, list specialized operations, and document a sequence of job steps along with associated hazards and recommended safety actions. A supervisor must sign off on the STA after reviewing it with crew members. Crew members then sign to acknowledge they understand the instructions and will comply with the assigned safety precautions.

Uploaded by

Rajkumsr V
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Emergency Action Plan: Provides a checklist for personal safety equipment and an overview of the emergency action plan for specific job tasks.
  • Safety Task Assessment Details: Outlines the steps to be followed for conducting a safety task assessment, including job steps, potential hazards, and recommended actions.

Safety Task Assessment (STA)

H S S E W O R L D . C O M

SAFETY TASK ASSIGNMENT (STA)


PLEASE REMEMBER TO REQUEST A COPY OF THE FIELD PROCEDURE
DESCRIPTION: DATE:

SHIFT: PROJECT NUMBER: FIELD PROCEDURE NAME AND NUMBER:

DAY NIGHT
SUPERVISOR:

EMERGENCY ACTION PLAN


ALARM DESCRIPTION: AREA AND/OR UNIT NUMBER:

NEAREST SHELTER / ASSEMBLY AREA: EVACUATION ROUTE DESCRIPTION:

DO I HAVE MY SAFETY GLASSES, STEEL TOES AND HARD HAT?


PERSONAL PROTECTIVE EQUIPMENT: HAZARDS BODY: (INDICATE BELOW IN DIAGRAM) HAZARD COMMUNICATION [HAZCOM]:
Gloves (Cut Resistant/Leather/Latex, etc) OTHER: Discuss Physical Hazards
Respirator Discuss Health Hazards
Hearing Protection MSDS Available
HEAD UNIT SPECIFIC TRAINING:
Safety Glasses/Goggles/Shields
Know Potential Hazards
Chem. Resistant Clothing/Coveralls EYES / FACE
FR Clothing/Jacket/Chaps Related to Job Task
Rubber Boots Other
Fall Protection ARMS GENERAL REQUIREMENTS:

Other Post Warning Signs


HOUSEKEEPING:
CHEST / UPPER BACK Relocate Flammables
Aisles Clean/Work Area Clean BODY
Barricades
Tools, Materials & Equipment Properly Stored ABDOMEN Ventilation/Exhaust
Waste/Trash/Scrap in Correct Containers Other
HAND
Other

SPECIALIZED / HIGH RISK OPERATIONS:: MISCELLANEOUS HAZARDS:


Lock Out/Tag Out Airborne Particulates
Confined Space Entry/Break the Line LEGS / LOWER Heat/Dehydration
Hydraulic Bolting (Hytorc, etc.) BODY Ergo/Awkward Postures/Positions
Scaffolding/Fall Protection Sharp Objects
Hot Work Permit Rotating Parts
Working on Energized Electrical Circuit Restricted Access
Hazardous Chemical Operations FEET Electrical Shock
Other Noise
Restricted Lighting
Other

H S S E W O R L D . C O M
Safety Task Assessment
H S S E W O R L D . C O M

• The Safety Task Assignment (STA) is a tool, just like a wrench or tape measure.
• It works by finding hazards and eliminating or minimizing them before the task is performed.
• Use your STA to create the dialogue between WL and crew members for job clarification and hazard awareness.
Note: Use the Company field procedures, work instructions, tool box talks book and request input from everyone in the crew to fill out this section. Standing in front of the
work area analyze other specific risks associated with the task
SEQUENCE OF BASIC JOB STEPS POTENTIAL HAZARDS RECOMMENDED ACTION/PROCEDURE OWNER (INITIALS)

SUPERVISOR / WORK LEADER: [PRINT NAME:] SIGNATURE: DATE:

I acknowledge searching for and minimizing risk, understand the supervisor’s instructions, and shall fully comply with the assigned task. If I am returning from
a break, then I have re-assessed my STA still adequate.

STOP WORK – YOU ARE THE LAST LINE OF DEFENSE

AFTER BREAK: AFTER LUNCH AFTER BREAK:


SSO NUMBER: SIGNATURE: INITIALS: INITIALS: INITIALS:

H S S E W O R L D . C O M

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