JOB HAZARD IDENTIFICATION Report No: Date:

CHECKLIST
SUPPLIER DATA INTERTEK DATA
Name: Intertek Project No.
Client P.O. / I.O.
Address:
to Intertek:
Attn: Phone: Requisition No:
E-Mail: Date of Order:

SUB-SUPPLIER DATA SUPPLIER/SUB-SUPPLIER INFORMATION

Name: N/A Inspection Performed:
Address: N/A With Customer Supplier With Sub-Supplier
Attn: N/A Phone: N/A Supplier PO:
E-Mail: N/A Date of Visit:
POTENTIAL HAZARDS/ NEAR-MISS / POTENTIAL HAZARDS/ NEAR-MISS /
SAFE UNSAFE SAFE UNSAFE
OBSERVATIONS IDENTIFIED OBSERVATIONS IDENTIFIED
Safe Work Practices / Procedures Access & Egress
Lockout / Tagout Housekeeping/ Clutter
Hazardous Communication Walkway / Stairs
Working At Height Ladders / Scaffolding /Gangways
Locations of Muster Points Safety Shower etc. Slips / Trips / Falls Hazards
Site Safety Requirements / Orientation Confined Space
Fatigue Management Other
Other Personal Protective Equipment
Working Environment Eyes / Ears Protection
Excessive Wind Hand / Head / Feet Protection
Wet Surface Fall Protection
Extreme Temperatures (Hot/Cold) Respiratory Protection
High Noise Levels / Vibrations Other
Moving Parts / Equip / Suspended loads Physical Demands
Energy Sources: Pressure / Electrical Standing for Long Periods
Protection from Welding / Grinding Work Climbing
Other Bending Squatting
Pinch Point Area
Other

Feedback / Comments / Corrective Action / Near-Miss Observation:

STOP WORK AUTHORITY UTILIZED

YES NO
(Must Contact Coordinator Immediately if “YES”)
Technical Specialist: Date: Intertek Project Coordinator:
Luis Bossa

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Organization Title/Subject Number
Intertek Industry Services Job Hazard Identification Checklist QA-308
Owner Approved by mm/dd/yyyy Revision Page 1 of 1
James A. Goree Andrew Jackson 08/01/2017 C